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COPYRIGHT DEPOSIT. 




PLATE I. 



BuccAi, Enanthkm in Measles (Koplik's Spots.) 

{Courtesy Dr. John Zahorsky.) 



THE 

DISEASES OF CHILDREN 



BY 

HENEY ENOS TULEY, M. D., 

LATE PROFESSOR OF OBSTETRICS, U]S'1VERSITY OF LOUISVILLE, MEDICAL DEPART- 
MENT; VISITING PHYSICIAN MASONIC WIDOM'S' AND ORPHANS' HOME, 
LOUISVILLE, KY. ; SECRETARY OF THE MISSISSIPPI VALLEY MEDICAL 
ASSOCIATION; EX-SECRETARY AND EX-CHAIRMAN OF THE SECTION 
ON DISEASES OF CHILDREN, AMERICAN MEDICAL ASSOCIA- 
TION; EX-PRESIDENT AMERICAN ASSOCIATION MEDICAL 
MILK COMMISSIONS, ETC. 



With One Hundeed and Six Engkavings 
AND Theee Colored Plates 



SECOND REVISED EDITION 



ST. LOUIS 

C. V. MOSBY COMPANY 
1913 






Copyright, 1913, by C. V. Mosby Company 



Press of 
C. Y. Mosby Company 
St. Louis 



©CI.A354084 



^ 



This Book 

Is Affectionately Dedicated 

To 

MY WIFE 

Whose Life has been a Constant 
Inspiration to Higher Endeavor 



PREFACE TO FIRST EDITION. 

This book has been written not for the specialist, but with 
the needs of the general practitioner and student in view, and 
the diseases of children have been described as they are seen 
by the busy practitioner in his daily rounds. 

Believing that the question of infant feeding is one of the 
most important which confronts us, much more space has been 
devoted to that subject than is given other important ones. We 
wish to interest the general practitioner in milk, its care and 
handling, the necessity for the formation of certified milk com- 
missions, and the establishment of milk depots where certified 
milk may be placed within the reach of the poor. 

Each disease is considered in a methodical manner. Special 
attention is given the dietetic and hygienic management, and 
the medicinal treatment is considered quite fully, with the repro- 
duction of many tried formulae. 

Chapters have been included on Diseases of the Eye, Ear, 
Nose and Throat, and the Skin. 

Temperature charts have been reproduced in a number of 
places, with the hope that this valuable clinical aid will be 
more often employed in private practice than it is at present. 
A world of valuable data and statistics is lost because of the 
practitioner's failure properly to record bedside notes in daily 
visits to the private patient. We would encourage this feature 
of the work. 

Thanks are herewith extended to Dr. Wm. Britt Burns, of 
Memphis, for the preparation of the chapter on Malaria; to 
Dr. Louis Frank and Dr. I. Lederman for valuable suggestions ; 
to Mrs. Mary West Fullenlove for painstaking preparation of 
the manuscript, and to the publishers for their many courtesies 
during the publication of the book. 

Henry Enos Tuley. 



PREFACE TO SECOND EDITION. 

The retirement of the Southern IMeclieal Publishing Company 
from the field of book publishing, and the acquirement of the 
publication rights to this book by the C. V. Mosby Company, 
necessitated the entire resetting of the book when it became 
apparent a second edition was needed. This has enabled the 
author to rewrite many chapters and make additions throughout 
the text that became necessary because of advancements and 
discoveries in pediatrics since 1909. Advantage has been taken 
also of this opportunity to make many corrections in the make-up 
of the book, as many typographical errors crept into the first 
edition. 

The general character of the book has been kept the same. 
The needs of the general practitioner and student have been 
kept in the front alwaj^s and as far as possible the views of the 
authorities in diseases of children have been given as well as 
the experience and observation of the author. 

New food formulae have been added and the suggestive stand- 
ards and methods for the production of Certified milk as 
adopted by the American Association of Medical ]\Iilk Commis- 
sions have been reproduced in full in the appendix, believing 
they may prove of value to many who may contemplate organ- 
izing a medical milk commission, or help to make better com- 
missioners of those already members of one. 

The old classification of the diseases of the gastro-intestinal 
tract has been retained with the full knowledge of its being un- 
satisfactory, but in tlie absence of a better one it was thought 
best to adhere to the old. 

A number of new illustrations have been added to this edi- 
tion, some to take the place of ones which had been lost, others 
entirely new. We are indebted to several authors and medical 
journals for the use of special cuts. 

Advantage is taken of this opportunity to express my thanks 



PREFACE TO SECOND EDITION. 

to the Publishers for their many courtesies, to my secretary, Miss 
Alice Lee Ford, for her invaluable assistance in the preparation 
of the manuscript, and for the generous reception accorded the 
first edition, which we bespeak for the second edition as well. 

Henry Enos Tuley. 
Aug. 1st, 1913. 



CONTENTS 

CHAPTER I. 

PAGE 

Anatomy of Ixfaxts 17-24 

Circulation — Head — Ear — Xose — Spine — Thorax — Larynx — Trachea 
— Lungs — -Thymus Gland — Bronchial Glands — Fetal Heart — Stom- 
ach — Sigmoid Flexure — Liver — Spleen — Kidneys — Testicles — L'te- 
rus — Ovaries — Heterotoxia. 

CHAPTER II. 

The New-boen 25-35 

Asphyxia — Care of the New-born^ — Preparation for the Baby — 
Care of the Napkins — ^^The Nursery. 

CHAPTER III. 

Diseases and Injuries of the Xew-born 36-52 

Caput Succedaneum — Cephalhematoma — Umbilical Hemorrhage — 
Granulating Umbilicus — Hemorrhage — L^mbilical Hernia — Atelec- 
tasis — Icterus — Sepsis — Injuries — Mastitis — Starvation Tempera- 
ture — Cerebral Hemorrhage — Tetanus — Sclerema. 

CHAPTER IV. 

Growth and Development 53-61 

Weight — Height — Progress — Dentition — Menstruation. 

CHAPTER V. 

Methods of Examination 62-73 

Physical Examination — Areas of Chest — History Taking — Diagnos- 
tic Signs — Temperature. 

CHAPTER VI. 

Therapeutics of Infancy and Childhood 74-86 

Dosage — Methods of Calculation — Varieties of Medication — 'The 
Bath — Pack — Local Application — Stomach Washing — Colon Irri- 
gation — Urine — Inunction. 

CHAPTER VII. 

Infant Feeding 87-151 

Infant Feeding — Breast Feeding — Nursing Motlier — Breast Milk — 
Wet Nurse — Weaning — Combined Feeding — Artiticial Feeding — 



CONTENTS. 

PAGE 

Cow's Milk — Certified Milk — Foreign Matter in Milk — Changes in 
Milk from Bacteria — Market Milk — Tuberculosis and Milk — Epi- 
demics due to Milk — Care of Milk in Home — Morbidity and Mor- 
tality Statistics Influenced by Milk — Sterilization and Pasteur- 
ization — Composition of Milk — Inspection of Dairies — Care of 
Bottle and Nipples — Modified Milk — Top Milk— Condensed Milk — 
Whey — Calories — Artificial Foods — Diet after First Year — Gavage 
— Eectal Feeding, 

CHAPTER VIII. 

Diseases of the Nose, Throat and Pharynx 152-171 

Acute Rhinitis^ — Chronic Rhinitis — Atrophic Rhinitis — Epistaxis — 
Nasal Polypi; — Diseases of the Tonsils — Acute Catarrhal Tonsillitis 
— Follicular Tonsillitis — Chronically Enlarged Tonsils — Uvulitis — 
Peritonsillar Abscess — Retropharyngeal Abscess — Adenoids — Dis- 
eases of Larynx — Acute Catarrhal Laryngitis — Congenital Laryn- 
geal Stridor. 

CHAPTER IX. 

Diseases of the Ear 172-186 

Diseases of the External Auditory Canal — Furunculosis — Impacted 
Wax — The Middle Ear — Acute Tubo-tympanic Catarrh — Acute 
Catarrhal Otitis Media — Acute Suppurative Otitis Media — Mastoi- 
ditis. 

CHAPTER X. 

Diseases of the Eye 187-199 

Eye Strain — Blepharitis — Herdeolum — Conjunctivitis — Trachoma — 
Grandular Conjunctivitis — Vernal Catarrh of the Conjunctiva — 
Diphtheritic Conjunctivitis — Phlyctenular Conjunctivitis — Oph- 
thalmia Neonatorum — Diseases of the Cornea — Pterygium — Phylc- 
tenular Keratitis — Intestitial Keratitis. 

CHAPTER XL 

Diseases of the Respiratory Tract 200-232 

Foreign Bodies in Bronchial Tubes — Asthma — Atelectasis — Acute 
Catarrhal Bronchitis — Chronic Catarrhal Bronchitis — Emphysema 
— Broncho-pneumonia — Lobar Pneumonia — Pleurisy — Empyema — 
Gangrene of Lung. 

CHAPTER XII. 

Diseases of the Digestive System 233-28B 

Diseases of the Lips — Ulcerations at Angle of Mouth — Herpes — 
Diseases of the Tongue — Diseases of the Mouth — Bednar's Aphthse 



CONTENTS, 

PACK 
— Stomatitis— Thrush — Raniila — Tongue-tie — Riga's Disease — Al- 
veolar Abscess— Fistula of Neck — Acute Esophagitis — Stenosis of 
Pylorus — Diseases of Stomach and Intestines — The Feces — Gastric 
Disorders — Acute Gastric Indigestion — Acute Gastritis — Chronic 
Gastritis— Gastric Dilatation— Cyclic Vomiting— Colic— Gastralgia 
—Acute Gastro-enteric Infection — Cholera Infantum — Acute Enter- 
eolitis — Chronic Entercolitis— Constipation— Dilatation of Colon. 

CHAPTER XIII. 

Intestinal Parasites 287-295 

Oxyuris vermicularis — Ascaris lumbricoides — Ankylostomum duo- 
denale — Tenia solium — Tenia Medicanellata. 

CHAPTER XIV. 

Surgical Conditions of the Intestine ' 296-306 

Appendicitis — Intussusception. 

CHAPTER XV 

General Diseases 307-367 

Typhoid Fever — Rheumatism — Diabetes Mellitus — Tuberculosis — 
Tubercular Meningitis — Tubercular Peritonitis — Pellagra — Malaria 
— Syphilis. 

CHAPTER XVI. 

Contagious Diseases 368-429 

Measles — German Measles — Scarlatina — ^Varicella — ^Vaccination — 
Vaccinia — Variola — Pertussis — Parotitis — ^LaGrippe — Diphtheria — 
Intubation — Intubation and Quarantine in Contagious Diseases. 

CHAPTER XVII. 

Diseases of the Circulatory System 430-450 

The Heart — Congenital Heart Disease — Pericarditis — Pericarditis 
with Effusion — Chronic Pericarditis — Pyopericardium — Endocar- 
ditis — Malignant Endocarditis — Chronic Endocarditis — Mitral 
Regurgitation — Mitral Stenosis — Aortic Regurgitation — Aortic 
Stenosis — Tricuspid Regurgitation — Tricuspid Stenosis — Treatment 
of Valvular Lesions — Functional Disorders of Heart — Bradycardia 
— Tachycardia — Acute Myocarditis. 

CHAPTER XVIII. 

Diseases of the Blood 451-468 

The Blood of Infancy and Childhood — Anemia — Pernicious Anemia 
— Chlorosis — Lymphatic Leukemia — Pseudoleukemia — Pseudoleuke- 
mia of Infants — Purpura — Hemophilia. 



CONTENTS. 
CHAPTER XIX 

PAGE 

Diseases of the Lymphatic Glands 469-475 

The Thymus Gland — Acute Adenitis — Chronic Adenitis — Addison's 
Disease — Cretinism. 

CHAPTER XX. 

Diseases of the Genito-urinary System 476-500 

The Urine — Albuminuria— Pyelitis— Renal Calculus — Perinephritis 
— Acute Parenchymatous Nephritis — Chronic Nephritis — Chronic 
Interstitial Nephritis — Tumors of the Kidneys — Hydronephrosis — 
Enuresis — Phimosis — Paraphimosis — Hydrocele — Balanitis — Ure- 
thritis — Vulvo-vaginitis — Cystitis — Undescended Testicle. 

CHAPTER XXI. 

Nutritional Disorders 501-512 

Athrepsia — Scorbutus — Rachitis. 

CHAPTER XXII. 

Diseases of the Nervous System 513-57-1 

General Considerations — Diagnostic Methods — Convulsions — Chorea 
— Hysteria — Epilepsy — Disorders of Sleep — Multiple Neuritis — 
Facial Palsy — Obstetrical Paralysis — Infantile Paralysis — Acute 
Myelitis — Pott's Disease — Tumors of the Spinal Cord — Syphilis of 
the Cord — Disseminated Sclerosis — Hereditary Ataxia — Hereditary 
Spastic Paralysis — Progressive Muscular Dystrophy — Meningitis 
— Epidemic Cerebro — Spinal Meningitis — Acute Encephalitis — Hy- 
drocephalus — Chronic Hydrocephalus — Cerebral Palsies — Tumors of 
Brain and Meninges — Abscess of Brain — Intracranial Hemorrhage. 

CHAPTER XXIII. 

Diseases of the Skin 575-597 

Intertrigo — Sudamina — Pediculosis — Scabies — Ringworm — Tinea 
Favosa — Impetigo Contagiosa — Pemphigus — Eczema — Herpes — 
Pruritus — Urticaria — Psoriasis. 

APPENDIX. 

Milk Modifications — Babies' Milk Fund Association Brochure — 
Refrigerator' — Methods and Standards for Production and Distri- 
bution of Certified Milk. 



ILLUSTRATIONS 

Plate I. Buccal Enantliem in Measles (Koplik's Spots) . Frontispiegie 

Plate II. Life-Cycle of Plasmodium Vivax .... Facing page 3X0 

Plate III. Tonsillar Diphtheria — Follicular Tonsillitis . Facing page 410 

FIGURE PAGE 

1. Capacity of infant's stomach . . 21 

2. Size of infant's stomach, three months 22 

3. Size of infant's stomach, six months 22 

4. Dissection of still-born child 23 

5. Funis Band Applicator 29 

6. Umbilical granulation removed by ligature six weeks after birth 38 
. 7. Adhesive strap for umbilical hernia 43 

8. Starvation temperature chart 48 

9. Hammock scale 53 

10. Nurserj^ scales 54 

11. Temporary and permanent teeth 58 

12. Showing axillary and infra-axillary regions 62 

13. Anterior regions of the chest 63 

14. Posterior regions of the chest » 63 

15. Position for taking rectal temperature 65 

16. Examination of throat by direct illumination 67 

17. Tongue depressor handle with removable wooden depressors . 68 
li8. Ear specula 68 

19. Bowles stethoscope with small chest piece 70 

20. Position for auscultation of back 71 

21. Auscultation of chest .72 

22. Stanton's percussion hammer 73 

23. Rubber bulb syringe 75 

24. Collapsible rubber bath tub 78 

25. Glass syringe 82 

26. Apparatus for stomach washing 83 

27. Colon irrigation 84 

28. Holt's milk set 91 

29. Certified Dairv No. 2 101 



ILLUSTRATIONS. 

FIGUEE PAGE 

29ti. Certified Dairy No. 2 102 

30. Certified milk bottle 104 

31. Certified milk in special glasses 104 

32. Curler milk pail IOC 

33. Hooded milk pail 106 

34. Certified milk shipping cases 100 

34a. Box used for collecting samples of milk in original bottles . . 107 
34b. Box used in collecting samples of milk in bulk 107 

35. Sample of unsuspected but dangerous tubercular cow . . . ,110 

36. Castle Pasteurizer 116 

37. Hygeia Pasteurizer 116 

38. Babcock butter fat test 129 

39. Chapin cream dipper . . . ■ 130 

40. Cross-section of human tonsil, age 11 years 156 

41. Osteomyelitis following streptococcic infection from tonsillitis . 160. 

42. Tonsillotome 162 

43. Croup kettle 170 

44. Instrument for paracentesis of the drum 176 

45. Otitis media both ears, temperature chart ....... 180 

46. Roller forceps for trachoma 191 

47. Five-cent piece in esophagus 201 

48. Vaporizer 207 

49. Lobar pneumonia; crisis seventh day. (Temperature chart) . 219 

50. Mucosa normal colon 283 

51. Mucosa giant colon 284 

52. Congenital idiopathic dilatation of the colon ..-..., 285 

53. Side view, same patient as above 285 

54. Eggs of oxyuris vermicularis 288 

55. Eggs of ascaris lumbricoides 290 

56. Head of tenia solium 293 

57. Head of tenia solium , 293 

58. Head of tenia saginata 293 

59. Typhoid fever with reinfection, temperature. (Chart) . . .310 

60. Typhoid fever; hemorrhage; perforation. (Temperature chart) 312 

61. Temperature chart for 81 da^s in child with general tuberculosis 333 

62. Same as above 333 

63. Pellagrous dermatitis 344 



ILLUSTRATIONS. 
FIGUEE PAGE 

04. Anopheles Crucians, Female mosquito, greatly enlarged , . . 348 

05. Anopheles punctipennis, Female mosquito, greatly enlarged . 348 
00. Anopheles quadrimaculatus. Female mosquito, greatly enlarged 348 

07. Anopheles mosquito at rest 348 

OS. Common mosquito at rest 348 

69. Malarial hemoglobinuria, temperature. (Chart) 358 

70. Measles, temperature. (Chart) 370 

71. Measles with complicating pneumonia, temperature. (Chart) . 372 

72. German measles, temperature. (Chart) 377 

73. The whooping-cough belt 404 

74. Eear view of the whooping-cough belt applied 404 

75. Laryngeal and nasal diphtheria; intubation. (Temperature 

chart) 414 

76. Diphtheritic casts of trachea and bronchi 416 

77. O'Dwyer Intubation Tubes 423 

78. Position for intubation. First step 425 

79. Intubation. Second step. Introducer about to be removed . 425 

80. Position for feeding child wearing intubation tube .... 426 

81. Tallquist hemoglobin scale . . 452 

82. Dare's hemoglobinometer 452 

S3. Locating the inter-vertebral space for lumbar puncture . . . 517 

84. Lumbar puncture. Nurse holding sterile bottle to catch fluid . 517 

85. X-ray of Pott's disease 546 

SO. Typical attitude assumed by patient with pseudohypertrophic 

muscular paralysis 554 

87. Same as Fig. 86 554 

88. Same as Fig. 86 554 

89. Typical muscular enlargement 555 

90. Pure culture of meningococcus, 30 hours old 557 

91. 92, 93, 94. Series of microphotographs illustrating the change in 

the cerebrospinal fluid under the influence of serum treatment 
with improvement 558 

95. Boy of eleven, ill forty-eight hours with epidemic meningitis . 560 

96. Boy of thirteen lying in the usual position of those ill with epi- 

demic meningitis 560 

97. Photograph of boy of ten and one-half years, taken five days after 

the onset of epidemic meningitis 560 

98. Hydrocephalus. Child six years old 566 



ILLUSTRATIONS. 

FIGURE PAGE 

99. Side view same child as in Fig. 98 566 

100. Pemphigus vulgaris acuta 588 

101. Pemphigus, temperature. (Chart) 589 

102. Westcott's milk modification chart 601 

103. Haas' Materna 603 

104. Deming Modifier 603 

105. Hess home-made refrigerator. Horizontal section .... 631 

106. Hess home-made refrigerator. Vertical section 631 



THE DISEASES OF CHILDREN 



CHAPTER I. 

ANATOMY OF INFANTS. 

The infant's anatomy differs from that of the adult in many 
essential points. The chief of these is the change which takes 
place in the circulation immediately after birth. These may 
be named as follows, probably in the order of their happening : 
Opening of the pulmonary arteries ; closure of the foramen 
ovale, complete about the tenth day ; disappearance of the Eu- 
stachian valve; obliteration of the ductus arteriosus, ductus 
venosus and the hypogastric arteries, the latter remaining pervi- 
ous from the internal iliac arteries to the bladder, known after 
birth as the superior vesical arteries. The umbilical vein and 
the ductus venosus close about the fifth day, the latter persist- 
ing in its impervious state as the round ligament of the liver. 
With the tying of the cord the hypogastric arteries and the ves- 
sels in the cord are obliterated. 

The child's head is very soft and compressible, the bones are 
ununited and separated by sutures; where the sutures coalesce 
are the anterior and posterior fontanelles. The anterior fon- 
tanelle, at the anterior superior end of the parietal bones is 
larger than the posterior and quadrilateral in shape. It closes 
during the second year. The posterior fontanelle at the poste- 
rior inferior ends of the parietal bones is triangular in shape 
and smaller. It closes by the end of the first year. 

As a result of moulding during birth the head in normal 
cases is much elongated from the chin to the occiput, and if a 
large caput succedaneum is present it is still further misshapen. 
Its normal contour is restored in a few days. The scalp is quite 
mobile, owing to its loose attachment to the aponeurosis. The 
frontal hone is divided into two equal parts ])y the frontal suture. 

17 



18 THE DISEASES OF CHILDREN. 

The sphenoidal and temporal bones consist of three separate 
pieces each. The mastoid cells are not present. The inferior 
maxilla is divided into two equal portions united by fibrous tis- 
sue at the chin. 

The infant's ear differs greatly from the adult's. At birth 
the axis of the meatus is directed upward, the canal being 
smaller at the inner end. The auricle is pulled dowm'(^ard to 
obtain a view of the tympanum. 

The Eustachian tubes in the infant are about half the length 
of the adult's; they are straight, and nearly horizontal, and the 
pharyngeal opening is about on a level with the hard palate, 
and smaller, relatively, than in the adult. 

The uose is small in infancy and the respiratory space in 
the nares very limited. The nasopharynx is quite deep. It is 
vascular and rich in lymphoid tissue. The presence of this 
lymphoid tissue is a menace to infants as it becomes easily in- 
flamed and swollen, obstructing the respiratory area. 

The spine is very flexible, the bones at birth are mostly carti- 
laginous, the nuclei of ossification being present. Spina bifida 
results from a failure of the laminae to unite allowing a pro- 
trusion of the membranes of the cord or filaments of the cord 
itself. The upper extremities are much better developed at birth 
than the lower, the fetal circulation providing a venous blood 
to the lower extremities. 

The clavicle is one of the first bones to ossify. The ossifica- 
tion of the long bones begins in the center of the diaphysis. The 
bones of the thorax are mostly cartilaginous, hence, the elasticity 
of this portion of the body. Several centers of ossification are 
present in the sternum. The larynx is higher than in the adult, 
being about on the level with the axis, and a view of the epi- 
glottis and vocal cords can frequently be had without the aid of 
a mirror. 

The trachea divides at about the third lumbar vertebra. The 
opening into the right lung is larger than the left, the right 
bronchus not having quite so wide an angle. 

The lungs at birth are small and the air vesicles entirely col- 
lapsed. On removing the anterior chest wall of a still-born 
child the lungs do not fill the thoracic ca^dtv and the heart is 



ANATOMY OF INFANTS. 19 

found uncoA^ered, the thymus g:land extending usually below the 
base of the heart. As a result of the first deep inspiration the 
air vesicles are dilated, the lungs expand, fill the cavity and 
cover the heart. The di\asion of the right lung into three lobes 
is quite marked in the infant, with a deep fissure especially 
posteriorly between each. The lower border of the right lung 
posteriorly, reaches the tenth rib on the right side, and to the 
eleventh rib on the left side. 

The thymus gland is an organ but little understood. It is 
present in the new-born, often being relatively of great size, 
gradually growing smaller after birth. It may extend as low 
as the fourth rib, and above the suprasternal notch. It has two 
lobes, and may measure 2^^ by IV2 inches. Its undue develop- 
ment has been supposed to be the cause of some otherwise unex- 
plained cases of sudden death. 

The hroncliial glands are located around the trachea in its 
lower portion and extend around the bronchi at their bifurca- 
tion. These are normally quite small, but as a result of an 
infection may assume quite a large size. 

The fetal heart differs from that of the new-born in the 
presence of the interauricular opening, the foramen ovale, and 
the Eustachian valve, which is supposed to guide the blood from 
the inferior vena cava through the right auricle into the left 
auricle. The cavities of the right side are larger than the left, 
the heart weighing about two-thirds of an ounce, at birth. With 
the change in the circulation after birth the heart assumes 
more the adult type, the left side becoming larger. The apex 
beat is felt about the fourth interspace farther to the left than 
in the adult. 

The fetal circulation is as follows: Leaving the placenta the 
blood flows through the umbilical vein to the lunbilical open- 
ing, ascending to the under surface of the liver from there 
through the ductus venosus, a fetal structure, to the inferior 
or ascending vena cava. From the inferior vena cava the stream 
goes into the right auricle guided by the Eustachian valve 
through the foramen ovale into the left auricle. From the left 
auricle through the mitral orifice to the left ventricle ; from 
the left ventricle to the ascendino: aorta, throui>h the larger ves- 



20 THE DISEASES OF CHILDREN. 

sels of the neck to the brain and upper extremities. The blood 
returns, via the superior or descending vena cava, to the right 
auricle, being largely venous in character ; from the right auricle 
to the right ventricle, the pulmonary arteries being impervious, 
the blood is carried through the ductus arteriosus, a fetal struc- 
ture, to the descending aorta. Through the descending aorta 
the blood flows as far as the iliac vessels, a portion of it going 
through the external iliac to the lower extremities, the rest of 
the blood going through the hypogastric arteries, branches 
of the internal iliacs, over the summit of the bladder and under 
the anterior abdominal wall to the abdominal opening where 
these vessels become the umbilical arteries. 

The umbilical opening may be patulous at birth and allow 
a protrusion through into the cord of a loop of the intestine, or 
there may be a separation of the umbilical ring after the stump 
of the cord falls off allowing a protrusion of intestine and the 
formation of an umhilical hernia. There have been a few cases 
reported where a coil of intestine had been included in a ligature 
which encircled the cord to tie the umbilical vessels. 

The stomach at birth is more like the dilated end of the esoph- 
agus than a separate organ itself, due to the pyloric end being 
pushed downward by the left lobe of the liver, causing it to as- 
sume more of the upright position. Regurgitation of its con- 
tents is very easy because of this. The stomach at birth will 
hold about 1 ounce. The cardiac opening is located about oppo- 
site the first dorsal vertebra, the principal difference in the intes- 
tine is the relatively large size and length of the sigmoid flexure 
of the colon. 

The sigmoid flexure at birth is about as long as the colon 
itself, the sigmoid extending frequently much beyond the median 
line. Owing to the shallowness of the pelvis most of the sig- 
moid is in the abdominal cavity. 

The liver is one of the heaviest organs in the body at birth, 
its relative w^eight to that of the body being 1 to 18. Its growth 
and development are due to its receiving first the pure arterial 
blood as it comes from the placenta. The left lobe may extend 
much beyond the median line. 

The spleen is small at birth, lying usually under the ninth 



ANATOMY OF INFANTS. 



21 



and tenth ribs, and cannot be felt upon palpation unless en- 
larged. The kidneys are about on a line with each other. They 
are distinctly lobulated'and may be joined, forming a horseshoe 
kidney. On section a number of uric acid infarcts may be 
found. 




Fi£ 



-Capacity of infant's stomacli (Kelley). 



The suprarenal glands are relatively larger at birth than in 
the adult. They are highly vascular and may be the site of 
hemorrhage. (See report of case on page 4(/.) Tlie male urv- 
thra will average two inches in length and shows (juite a distinct 
constriction at the meatus. The fossa navicularis is relativelv 



22 



THE DISEASES OP CHILDREN. 




Fig. 2. — Size of infant's stomach three months (Kelley 




Fig. 



3 — Size of infant's stomach six months (Kelley). 



ANATOMY OF INFANTS. 



23 



larger than the rest of the urethra and may be the site of the 
formation of a concretion or stone in late infancy. 

The corona glandis is tightly covered by the prepuce, fre- 
quently adherent, with an accumulation of smegma behind the 
corona o-landis. 




Fig. 4. — Dissection of still-l)oni child. Note tlie course of the sigmoid, 
relatively large size of the liver. 



The testicles in the embryo are found in the abdominal cavity, 
below the kidneys, in the lumbar region. At about the eighth 
month they descend and pass out into the scrotum through the 
inguinal canals. 

A child whose testicles are retained within the canal or cavity 



24 THE DISEASES OF CHILDREN. 

is called a cryptorchid, if only one has descended, a monorchid. 

The uterus at birth is small, about 1 inch in length; the 
ovaries are found in the lumbar region in intrauterine life, and 
at birth are as low as the brim of the pelvis. It is estimated 
that upwards of 75,000 ova are in each ovary at birth. 

The relative weight of the hrain at birth to the body is 1 to 8. 
The color is quite pale and contains a larger percentage of 
water than the adult brain. 

HETEROTAXIA. 

Irregular malpositions of viscera are occasionally observed in 
routine practice. These abnormalities have been exhaustively 
studied by Ballantyne, Osier, Arneill, Rover and Wilson. 

The usual form observed is a complete transposition, of either 
the thoracic or abdominal organs or both. 

Among the remarkable cases on record (Arneill ^ reporting 
300 collected from the literature) are maintenance of fetal vascu- 
lar conditions after birth; lobulated spleen or multiple spleens; 
one kidney; transposition of the cavities of the heart; of the 
lungs, liver and spleen. 

The fetal condition of the heart can be made out by physical 
examination. The other transpositions may not be suspected 
until found postmortem, and unless the heart is involved 
the child may reach adult life; with involvement of the heart 
these children rarely reach puberty. 

1 American Journal Medical Sciences, November, 1902. 



CHAPTER II. 
THE NEW-BORN. 

As soon as the child's head is born, and before the birth of 
the body, feeble attempts are made at inspiration. At this time 
the mouth should be wiped out promptly and freed of the mucus 
and fluid which it contains in order to prevent its being aspi- 
rated in the bronchial tubes, with the first deep inspiration. 

Reacting to the stimulus of the air upon the skin, the first 
inspiration is taken and the air vesicles are dilated. The skin 
quickly changes from a pallid or bluish color to the normal red, 
and the child criea lustily. The respirations at first are shal- 
low, often slightly irregular, and they are of the abdominal 
type. The chest soon becomes fully expanded and the number 
of respirations which at first was 60 or 70 to the minute will 
average about 40 at the end of the first hour. 

ASPHYXIA. 

"Where insufiicient air has entered the lungs of the new-born 
to dilate the air vesicles the child is still-horn. When some air 
does enter the lungs and for any reason there is an interference 
with the proper exchange between oxygen and carbon dioxide, 
the condition is called asphyxia. 

Forms. — Asphyxia may be intrauterine. This form is caused 
by any interference with the uteroplacental circulation; as a 
premature or accidental separation of a portion of the placenta; 
knots in the cord, too tight loop or loops of the cord around the 
child 's neck ; long-continued labor from any cause ; compression 
of the cord by the after-coming head ; compression of the fetal 
brain by forceps operation ; death of the mother and prema- 
turity. 

Intrauterine asi)hyxia may be foretold liy tlu^ ])remature 
escape of meconium in vertex pres(4itations nnd by an inter- 
ruption in the beat of the fetal heart, either very rapid or very 
slow heart sounds. In interference AAdth placental respiration. 



26 THE DISEASES OF CHILDREN. 

the blood of the fetus is surcharged with carbon dioxide, an 
increased intestinal peristalsis and a relaxation of the sphincter 
occurs, allowing escape of the meconium. In breech presenta- 
tion, the escape of meconium is from pressure causes entirely, 
and is of no significance. 

If premature respiration occurs before the birth of the head, 
liquor amnii and mucus may be aspirated, which will mechan- 
ically act as a cause of asphyxia. 

The persistence of the intrauterine apnea after birth con- 
stitutes the postnatal form of asphyxia. The chief cause of 
this form is an injury to the respiratory centers by prolonged 
labor; prematurity, the thin chest walls making it impossible 
for the lungs to dilate because of external atmospheric pressure, 
a general atelectasis following in these cases. 

Symptoms. — In the intrauterine form of asphyxia, the child 
is born limp and the skin is pale or blue. Two forms are gen- 
erally referred to, asphyxia livida and asphyxia pallida, the 
latter being the most profound. In the mild cases there is a 
very feeble intake of air, noted by slight movement of the dia- 
phragm, strong umbilical pulsation and muscular action of the 
face and nose. If improvement follows, the respirations will be- 
come more regular and less spasmodic, the color will improve 
and the child will utter a feeble whine or cry. 

Prognosis. — The prognosis in all cases of asphyxia is very 
grave. Atelectasis is always to be feared. If the child does not 
nurse well, has a persistent subnormal temperature and pro- 
gressive and rapid loss in weight, the prognosis is more grave. 
As long as there are any heart beats to be heard one should 
persist in efforts at resuscitation by artificial respiration. 

Treatment. — Prophylaxis of asphyxia should be borne in mind 
in every case of labor. Intelligent interference in cases of pro- 
longed labor with the fetal heart as a guide is always indicated, 
and will prevent many cases of asphyxia. The mouth and nose 
should be carefully cleansed of mucus and the face not allowed 
to remain in the discharges upon the bed or table, if the delivery 
is accomplished in the dorsal position. A basin or tub which 
will hold enough Avater to completely cover the child's body, 
should be part of the equipment of every delivery room, as fre- 



THE NEW-BORN. 27 

quently respiration Avill be stimulated by immersing the -child 
in water at a temperature of 105° or 110° F., and occasion- 
ally allowing a small quantity of cold water to trickle over its 
chest or plunging it for a second in cold water. If this fails, 
resort should be had at once to the use of one of the methods of 
artificial respiration. 

A soft catheter may be introduced into the trachea and mucus 
aspirated through it, if the obstruction seems to be of that na- 
ture. The suspension of the child by its feet, and tlagellalion 
of back and buttocks serve to allow drainage from the lungs, 
stimulates the medulla by rush of blood by gravity and by 
reflex action through the skin, aids in respiration. It should 
be then plunged into the hot bath at once. 

The Byrd-Deic method can be used to advantage with the 
child immersed in the water. This method consists in holding 
the child upon its back in the palms of the hands, the head 
supported by one hand. Expiration is produced by bringing 
the pelvis toward the chest, arching the spine backward and 
compressing* the lungs. Inspiration is produced by raising the 
ulnar sides of the hands, thus arching the spine forward. At 
the same time the head is allowed to fall back, thus straighten- 
ing the trachea and aiding inspiration. 

With all the methods of artificial respiration, mouth to mouth 
insufflation is of benefit as it dislodges mucus concealed in the 
nasopharynx and forcibly dilates the air vesicles. The child's 
mouth is covered with a piece of gauze, the operator holds the 
child's nose, slightly compresses the epigastrium, places his lips 
to the child's and blows air into the child's mouth, after slight 
compression of the chest to accomplish expiration. . This may 
be repeated once or twice, a fresh piece of gauze being used or 
a fresli area covering the moutli. 

Artificial respiration should not be used oftener than thirty 
times to the minute. 

In Sylvester's method the child is placed upon its back, a 
folded towel under its shoulders, and chin raised. The op- 
erator, standing at the head, draws its anus over its head for 
inspiration, and for expiration carries them down over the chest, 
at the same time making pressure on the chest wall. 



28 THE DISEASES OF CHILDREN. 

In Schultze's method the child is supported with the index 
fingers in the axilla with its back to the operator. Expiration 
is produced by raising the child and allowing the feet to fall 
forward over the face, thus compressing the diaphragm. Inspi- 
ration is produced by allowing the child to fall forward into the 
first position, with the head fully extended, thus straightening 
the trachea. 

Laborde has suggested that rhythmic traction on the tongue, 
acting through the recurrent laryngeal nerve, may stimulate 
respiration. 

Dilatation of the sphincter ani with the finger is a stimulant to 
respiration, and should be used in connection with the other 
methods. 

The piilmotor, a mechanical device for artificially inducing 
and maintaining respiration, has been successfully used to es- 
tablish respiration in asphyxia of the new-born. It is of 
greater value than the other methods of artificial respiration as 
it forces oxygen into the lungs. 

CARE OF THE NEW-BORN. 

Authorities differ as to the proper time to ligate the cord. 
The child unquestionably has a better start if all of the blood 
in the placenta can be utilized in its own vessels after birth, 
hence, ligation of the cord, when the pulsations have ceased, at 
about 10 inches from the child's abdomen, provided respira- 
tion has been prompt, gives the child this advantage. The cord 
is ligated 2 inches from the abdomen and a second ligature is 
applied, between which the cord is cut. The ligature material 
should either be a rubber elastic band, tape or very heavy silk. 
By using a rubber band which can be applied by means of one 
of several applicators on the market, continuous pressure is ex- 
erted on the vessels as the Wharton's jelly atrophies, and hemor- 
rhage from the cord prevented. If tape or silk is used the cord 
should be frequently inspected during the first hour or two 
after birth to guard against hemorrhage. The cord may be 
dressed with a piece of sterile gauze 3 inches square, cut half 
across its middle. The cord is drawn through this cut and over 
it can be poured a dressing* composed of balsam of Peru and 



THE NEW-BORN. 



29 



castor oil/ or a powder composed of 
one part salicylic acid and three parts 
of boracic acid. Over the cord is then 
placed an uncut piece of gauze and all 
is confined by a flannel binder 6 inches 
wide, applied snugly but not tightly. 
This dressing is not removed except it 
be to renew the oil or the powder until 
the cord drops off, which usually oc- 
curs between the fourth and seventh 
days. I have seen one cord remain at- 
tached for 18 days. If at the end of 
10 days the vessels are still attached a 
ligature should be tied close to the um- 
bilicus and the stump cut away. The 
umbilicus should be left perfectly 
smooth and dry after the cord drops 
off; if moist, a few applications of 2 
to 4 per cent solution of nitrate of sil- 
ver 'and a drying powder will usually 
suffice. The flannel binder is only 
worn for the purposes of preventing 
an accident to the cord before it sep- 
arates, and a knit binder is substituted 
for it at the end of two weeks. 

Too' frequently a new-born child is 
neglected by the attending physician. 
As soon as the cord is cut, it is given 
to the nurse, and not again looked at. 
Every child should be carefully in- 
spected by the physician before it is 
dressed. Its mouth should be exam- 
ined for presence of cleft palate ; ex- 
tremities for deformities; genitals and 
anus for abnormalities ; scrotum for the 
presence of the testicles. At the end 
of six 'or eight hours, inquiry should be made to learn whether 




Pis-. 



Funis Band Applicator 
Uvellog-g-). 



1 Balsam of Peru, Til- 20; castor oil, one ounce. 



30 THE DISEASES OF CHILDREN. 

the bladder and rectum have been evacuated. If the passage of 
urine seems painful, this may be due to a constricted, pinhole 
prepuce, or to the passage of uric acid sand with the urine, the 
latter being present on the napkins and easily seen. If no me- 
conium has been passed the rectum should be inspected for an 
imperforate anus, and if this is found appropriate measures 
taken at once for its relief. 

The skin is covered with a cheesy-like substance called vernix 
caseosa. This is accumulated to a considerable extent in the 
flexures and folds of the skin. This substance can be easily 
removed, if disintegrated by the application of some oily sub- 
stance. Vaseline, olive oil or unsalted lard is rubbed over the 
child's body thoroughly, the face being wiped off with a greased 
piece of gauze. A shirt and napkin are applied and the child 
wrapped in a blanket and laid upon its right side in either a 
crib or bassinet. A useful bassinet can be made of a wicker 
clothes basket which has been padded and a pillow placed in the 
bottom upon which the child is laid. At the end of four or five 
hours the child is given its first bath while lying upon the 
nurse's lap, water at the temperature of 100° F. is used and the 
vernix removed with a soft cloth without violence. The skin 
is thoroughly dried and pure talcum used in the folds and 
flexures of the skin. 

Eyes. — Crede's treatment of the eyes for the prevention of 
ophthalmia neonatorum sJiould he used in every neiv-horn hahy's 
eyes. No patient can positively be said to be free from gono- 
cocci, and if the treatment is reserved for those cases where 
there is a history of a purulent vaginal discharge in the mother 
before delivery, many severe cases will be encountered. The 
treatment is of itself entirely harmless, and an absolute prophy- 
lactic. One or two drops of a 2 per cent solution of nitrate of 
silver are dropped into each eye, at the outer canthus. Normal 
salt solution is then squeezed into each eye from a pledget of 
gauze or medicine dropper, to neutralize any excess of the silver. 
If any irritation results from this treatment it is very slight and 
transitory. Other salts of silver have been suggested as a sub- 
stitute for the nitrate, as argyrol, but none are as effective as 
the one first suggested by Crede. 



THE NEW-BORN. 31 

Mouth. — As a routine the mouth should be washed with 
boracic acid solution before and after each nursing, before nurs- 
ing to protect the mother's nipple, and after, to remove any 
particles of milk remaining in the folds of mucous membrane. 
The development of thrush or sprue is an evidence of careless- 
ness and neglect. A swab of soft sterile gauze or absorbent 
cotton is made on the end of the little finger and wet with 
boracic acid solution, and the whole of the inside of the mouth 
carefully and gently swabbed. Violence should be guarded 
against as an abrasion of the mucous membrane from too vig- 
orous rubbing may be the site of an infection. 

Bathing. — The child should be given a daily bath upon the 
lap until the cord drops off, the baby being partly covered with 
the bath blanket. Only pure castile soap should be used in the 
bath. When the cord has dropped off and the navel is healed, 
the baby should be soaped while in the lap, then immersed in a 
baby's bath tub. The tub can be made collapsible, of rubber 
sheeting, supported on legs of the proper length, so as to make 
it the correct height to be comfortable and convenient for the 
mother or nurse. If a small white porcelain tub is used it should 
be placed on a chair or stool. A folded bath towel should be 
laid on the bottom of the tub, to prevent the child slipping. 

The temperature of the water should be 100° F. After the 
baby is a month old the water should be cooled to 90° F. before 
the child is removed. When removed from the water it is 
wrapped in the bath blanket, carefully dried, the buttocks and 
flexures powdered, and dressed immediately. The bath should 
always be given before nursing, never just after being fed. It 
may be found most convenient and comfortable to the child to 
give the bath just before the last feeding at bed time. In hot 
weather a second bath may be given at bed time. 

A folded napkin can be placed under the child to soak up 
any urine which penetrates the first one. Rubber napl'ius 
should never be used. 

Buttocks. — The first discharge from the bowels is meconium. 
It is composed of epithelial cells and biliary salts, is black and 
of the consistence of tar. It is difficult to remove from the 
skin, and when it remains in contact with it for some time in'i- 



32 THE DISEASES OF CHILDREN. 

tation and maceration take place, and an intertrigo follows. An 
intertrigo is always the sign of carelessness. As soon as soiled 
the napkin should be removed and the skin very gently washed 
with a soft cloth and water, without soap, and carefully dried 
and powdered. 

Genitals. — The female genitals need but little care except ordi- 
nary cleanliness and prompt removal of soiled napkins both 
day and night. The possibility of the development of a vulvo- 
vaginitis, either simple or specific, should be borne in mind. The 
treatment of the latter is referred to in another place. 

Indiscriminate and universal circumcision of a male infant 
should not be advocated. If, when the baby is a month old, the 
prepuce is reflected, adhesions broken up and the smegma re- 
moved, and vaseline placed well around the corona glandis, the 
necessity for circumcision is averted. This will prevent the 
pinhole opening and long prepuce so frequently seen in boy 
babies in whom this precaution has been omitted. This reflec- 
tion should be repeated once every second day for a week, then 
once a week, for the sake of cleanliness. I have seen one case 
in which an infection occurred after the first reflection at the 
site of one of the abrasions where a rather tight adhesion had 
occurred, and considerable pus accumulated behind the corona, 
this being possible as the mother had failed to again completely 
reflect the prepuce to cleanse it. The mother should be cau- 
tioned in regard to the possibility of a paraphimosis developing 
from allowing a prepuce to remain reflected behind the corona 
too long at a time. 

No infant should ever be allowed to sleep in the same bed 
with its mother. 

PREPARATION FOR THE BABY. 

The baby's basket should be prepared some weeks before 
birth, and the following articles for it are suggested : 

Pin-cushion containing three sizes of safety pins. 
Soft hair brush. 

Soap box with wliite castile soap. 

Talcum powder in box witli perforated top. [Powder Puff is un- 
hygienic. ) 



THE NEW-BORN. 33 

White vaseline in tube. 

Benzoinated oxide of zinc ointment. 

Bath thermometer. 

Hot-water bag, two-quart, with removable flanellette bag with draw 

string. 
Saturated solution of boracic acid. 
One pair blunt scissors. 
Absorbent cotton, wrapped in small towel. 
Soft towels made of old damask. 
Apron bath blanket of outing flannel made of two thicknesses sewed 

together at the top only. 
Wooden tooth picks to be wrapped with absorbent cotton at one end to 

be used as swab for cleaning nose. 
Two or three thin flannel bands, six inches wide. 
Soft linen of double thickness, or cheese cloth for wash cloths. 
Squares of sterile gauze for washing mouth. 
Medicine dropper. 

A box or special drawer should be provided for the baby's 
clothes. The outfit should consist of the following: 

Four dozen napkins made of cotton birdseye, two sizes, 20 inches and 

24 inches wide. Either square or double. 
Six flannel skirts. 
Four silk and wool shirts. 
Four knit bands. 
Four outing flannel gowns. 
Nine white slips, nainsook or longcloth. 
Three white cambric petticoats. (To be worn only in summer, and not 

with flannel ones.) 
Two white baby blankets or comforts. 
Two knitted sacks. 

Two or three quilted pads for baby's bed, one yard square. 
One cloak — two caps — one veil. 
Two pieces rubber cloth, one yard square. 
Fine hair pillow, 10 x 12 in. for buggy. 
Six pillow slips. 
Six sheets for bassinet. 
Skirt stretcher. 
Stocking stretcher. For drying these garments without shrinking 

them. 
One flannel bag for tying about child's waist when out of doors. 

]\Inch help can be had in making the baby's clothes by using 
Butterick's fashions, set No. 7080. 



34 THE DISEASES OF CHILDREN. 

CARE OF NAPKINS. 

Too great emphasis cannot be laid on the importance of 
careful washing of the napkins, both when soiled with a move- 
ment from the bowels and when wet with nrine only. They 
should be washed with soap and soda, followed by several rins- 
ings in cold water, and dried out of the nursery, folded smooth 
by hand and not ironed, as ironing renders them less absorbent. 
I have seen several cases of severe eczema, limited to the part 
of the body covered by the napkin, where inquiry developed the 
fact that the napkin was being used after being wet three or four 
successive times and simply dried without washing. 

As soon as a napkin is soiled it should be taken to the bath 
room or closet and the movement scraped off with a knife kept 
for that purpose, wiping tlie scrapings on a piece of toilet paper 
and throwing it in the closet. The diaper is then put in a 
covered porcelain bucket, which should be provided, containing 
a weak formaldehyde solution or a 1 to 100 carbolic acid solu- 
tion in which the soiled napkins can be placed until washed. 

THE NURSERY. 

The nursery should be a bright cheery room, with an open 
fireplace for winter heating, if possible. The temperature 
should not be over 70° F., and the air should be changed at least 
once daily, first removing the child and opening all windows for 
a half to one hour. It should have not less than 1000 cubic 
feet of air space, and more if possible. Emphasis should be 
laid upon the importance of a moist air in steam-heated or hot- 
air-heated houses. 

The walls should by preference be painted and the floor un- 
carpeted, either hardwood or painted. This makes it possible 
for the floor to be wiped up and not swept, thus avoiding dust. 
The use of a compressed air-cleaning device in private houses 
should be recommended, where there are children, especially. 
There should be plenty of light, when the child is awake, with 
dark shades to darken the room when asleep, and the room should 
be at least 5° cooler at this time. In favorable weather the child 
can sleep in its buggy out of doors, protected from the wind and 
its eyes from the light. 



THE NEW-BORN. 35 

The skin of the new-born is very delicate, and is covered with 
lanugo, a fine downy hair, which is soon rubbed ot¥. There is 
frequently desquamation of the skin, either general or on vari- 
ous parts of the body. 

Most infants have a rather heavy suit of hair, at birth, and 
during the first three months this is usually rubbed off, first 
on the back of the head, where it comes in contact with the bed, 
and this is replaced by a finer and softer growth. 

In the new-born the temperature is usually elevated 1° or 2° F. 
A large number of observations made by Edwards, Keating and 
Holt, have demonstrated that the temperature in infants, be- 
tween ages of one and twelve months, ranges between 99° F. 
and 99.5° F., and that only a temperature of 100° F. or over 
should be considered as abnormal. A continuous subnormal tem- 
perature is one of the best indications of poor nourishment. 

If no deformity exists, an infant should pass urine during 
the first two or three hours after birth. The first secretion is 
usually clear, but it may become turbid, or contain a deposit 
sufficiently thick to stain the napkin, or distinct particles of 
uric acid sand may be passed. Some pain is usually experi- 
enced when the latter is passing. The urine later in infancy 
is very light in color and of low specific gravity. 



CHAPTER III. 

DISEASES AND INJURIES OF THE NEW-BORN. 

Caput Succedaneum. — This is a collection of blood serum in 
the cellular tissue of the presenting part of the child. It is due 
to a constriction of the veins of the skin by the bony pelvis 
preventing a free return of the blood and allowing- an escape 
of the serum into the cellular tissue. It is present at birth, and 
in vertex presentations, the scalp may be thick enough to 
make it impossible to detect any of the sutures or fontanelles. 
The extravasation has usually been absorbed by the end of the 
second day, and the scalp and head have a normal appearance. 

Cephalhematoma. — This is an extravasion of blood from a 
ruptured capillary between the periosteum and the bone. It 
usually does not occur until the third or fourth day, and is most 
frequently found over one or both parietal bones. The extrava- 
sation of blood is limited entirely tO' the bone over which 
it occurs, as the periosteum is bound down to the edges of the 
bone. If over both parietals, there is a deep sulcus between, 
corresponding to the sagittal suture, and looking at the head 
from behind it has the appearance of two half oranges under 
the skin on opposite sides. 

Cephalhematoma must be differentiated from hernia cerebri. 
In the latter the tumor is a pulsating one and in cephalhematoma 
it is not. Crying will increase the tension of a hernia but 
causes no change in the cephalhematoma. Cephalhematoma is 
not always due to injuries sustained in prolonged, natural or 
instrumental deliveries, in vertex presentations. As an instance 
may be mentioned two cases under my observation, both in 
breech presentation. One was a double cephalhematoma, the 
other triple, hemorrhage occurring over both parietal and the 
occipital bones. 

In rare instances suppuration ensues, in which event all the 

36 



DISEASES AND INJURIES OF THE NEW-BORN. 37 

signs of an abscess will be present, and surgical intervention 
is called for at once. 

Treatment. — The temptation is to interfere in cases of 
cephalhematoma, but under no circumstances should they be 
interfered with. If protected from injury from pressure, na- 
ture takes care of the effused blood by absorption, and in the 
majority of cases after being absorbed, no trace of them can be 
found, unless it be a small ridge at the extreme edges of the 
tumor. Incision may be practiced under the strictest aseptic 
precautions, but the difficulty of maintaining pressure upon the 
head to prevent the further effusion of blood after evacuation 
of the clot must be borne in mind. 

Umbilical Hemorrhage. — Hemorrhage from the cord may 
occur before it drops off, either from a loosely applied ligature 
or from the vessels being cut through by a small ligature being 
tied too tightly. Both of these accidents can be prevented by 
'the use of a rubber elastic ligature, in the form of a small 
rubber ring ' of caliber smaller than the circumference of the 
cord, which is stretched and slipped over the severed end of the 
cord, by one of the appliances for that purpose. A ligature of 
this kind exerts continuous pressure on the vessels as the Whar- 
ton's jelly dries, and bleeding is more effectually prevented 
than can possibly be done by any other means. 

Hemorrhage may occur from the umbilicus after the cord has 
dropped off, during the second or third week, and in all such 
cases there is a tendency to hemorrhage as is found in hemo- 
philia or the ''bleeders." 

Pressure upon the bleeding vessels at this point is very diffi- 
cult to accomplish. If there is but a small amount of oozing, 
the application of persulphate of iron or a one to one thousand 
solution of adrenalin may control it. Needles carried under the 
umbilicus at right angles, and wrapped with a figure of eight 
suture should be tried in the severer cases. 

Granulating Umbilicus. — After the separation of the cord, 
one or more of the vessels may be left as a small granular spot, 
from which there is a serous, or seropurulent discharge, an 
eczema of the skin of the umbilicus sometimes following. 

Treatment. — A cure may be had by the application of a solu- 



88 



THE DISEASES OF CHILDREN". 



tion of nitrate of silver, 30 to 40 grains to the ounce, followed 
by a dry, absorbent dressing, as powdered boracic acid and 
starch, equal parts, this being repeated once daily. 

In the event that there is a protrusion of the stump of the ves- 
sels, after the cord drops off, a silk ligature should be thrown 




ri£ 



6. — Umbilical granulation removed by ligature six weeks after birth. 



around its base and tied tightly. When this stump separates 
it will promptly heal under a dry dressing. 

Hemorrhag'e. — New-born babies are specially prone to de- 
velop hemorrhages, and because of the indefinite knowledge to- 
day of the true pathology of the condition, the symptom complex 
is now called in general terms, '^hemorrhage of the new-born." 
Formerly an attempt was made to describe each case according 
to the location of the hemorrhage, in this way having a number 



DISEASES AND INJURIES OF THE NEW-BORN. 39 

of terms, descriptive of the same general underlying disease. 
Kling, Genrich and Runge, quoted by Koplik, state tliat hem- 
orrhagic disease in the new-born occurs about once in 1000 cases. 

Etiology. — The etiology of the condition is obscure; but in 
view of the fact that fever is a prominent symptom in most 
cases, the consensus of opinion is that the most frecfuent causa- 
tive factor is a general septic infection. The new-born develop 
sepsis easily and the entrance to the system of the offending 
organisms may be at many points, the gastrointestinal tract, 
the mouth, the genitourinary tract and the umbilicus being the 
most frequent portals. Gartner claims to have found bacilli 
in the feces in cases of melena, proving his theory that this 
form of hemorrhages is a coccal sepsis. In AVinckel's disease, 
a condition closely similar, a bacteremia is present, streptococci 
and bacilli having been found in various organs and the blood. 
The changes whcli occur in syphilis, which has been named as a 
cause, are in the blood vessels rather than in the blood itself. 

Among the other causative factors have been mentioned pre- 
maturity, atelectasis, deformity of the heart, persistent foramen 
ovale or ductus arteriosus, ulcer of the stomach and intestine, 
the latter due to a venous stasis, followed by a thrombosis ; fatty 
degeneration of the arterioles.; extreme delicacy of the blood 
vessels ; congenital obstruction of the portal venous system ; con- 
gestion from pulmonary^, cardiac or hepatic disease; excessive 
secretion of gastric juice resulting in partial digestion of the 
mucosa of stomach and intestine, congenital hemophilia and the 
gTeat changes taking place in the circulation incident to birth. 

Hemorrhages in the new-born may take place from any organ 
and the hemorrhage may occur before birth or subsequently. 
When postnatal, it usually occurs within the first three days 
after birth. 

In Dr. Townsend's 50 cases, cpioted by Rotch, he gives the fol- 
lowing location of the hemorrhages : 

Intestines 20 Ecchymoses in Skin 21 

Stomach 14 Scratch of Skin 1 

Nose 12 Cephalhematoma 3 

Mouth 14 Meninges 4 

Umbilicus 16 Abdominal Cavitv 2 



40 THE DISEASES OF CHILDREX. 

Pleural Cavity 2 clivmosis of skin 3 

Lung 1 G astro-enteric tract alone ...... 10 

Thymus Gland 1 From umbilicus alone 3 

From Gastro-enteric tract, nose, Fcchymoses of skin alone 6 

umbilicus accompanied by ec- 

Holt gives Eitter's statistics in 190 cases as follows: Hemor- 
rhage from the umbilicus. 138 ('umbilicus alone. 97) ; intestines, 
39 : mouth, 28 : stomach. 20 : conjunctivae, 20 : ears, 9. 

I have seen one case of hemorrhage into the suprarenal gland, 
a number of cases of cephalhematoma, both single and double, 
and the case shortly to be reported, of melena. or hemorrhage 
from the stomach and intestine. In the case of hemorrhage in 
the suprarenal capsule, reported in full in the Archives of 
Pediatrics, November, 1892. the right suprarenal gland was 
distended with blood to the size of an orange, and blood clots 
were found behind the kidney and in the free peritoneal cavity. 
The diagnosis was not made in this case during life, the most 
prominent sy^nptom being a profound jaundice. The hemor- 
rhage was found postmortem. 

Hemorrhage from the gastrointestinal tract may occur inde- 
pendently of bleeding from any other organ and is called 
melen^e. If from the mouth alone, the quantity of blood lost is 
usually small, if from the stomach large quantities may be vom- 
ited or passed from the bowel in form of clots. As stated, it 
has been thought by different observers to be due to an ulceration 
of the mucous membrane, following septic emboli of its vessels, a 
digestion of the membrane by a hyperacid gastric juice, or to 
a general pyogenic septic condition. Like the other forms it 
usually occurs during the first three days, and with great variety 
as late as the ninth day. The child may first vomit some red 
blood, followed soon afterward by a coffee-ground vomit, or 
blood may first be noticed in the discharges from the bowel. The 
meconium, being very dark in color, may cause blood in the 
actions to be overlooked, unless it is passed in large clots. If 
passed in considerable quantity the napkin at the edge of the 
mass will be stained a reddish color, or if blood is suspected 
a. microscopic examination will reveal the blood corpuscles. It 
should be borne in mind, before a diagnosis of hemorrhagic dis- 



DISEASES AND INJURIES OF THE NEW-BORN. 41 

ease is made, that the source of blood may have been a fissured 
nipple, or blood from the nose which has been swallowed. I 
have seen one case which caused considerable uneasiness until 
it was finally decided that the source of the blood was from a 
cracked nipple. 

Prognosis. — The prognosis in hemorrhagic diseases of the new- 
born varies according to the site of the bleeding. Taken as a 
whole the mortality is given by various authors differently: 
Townsend's cases 62 per cent, and in another series of 709, 79 
per cent ; Williams places it at 60 per cent ; Holt states that 
no observer has seen more than one-third of his cases recover. 

The following history is given as illustrative of that form of 
hemorrhage kno\^TL as melena : 

Child of III Gravida. First labor instrumental, occiput posterior, forceps 
rotation. Second labor normal, but prolonged. Third labor began at 12 
midnight, birth at 1 p. m. following day. Vertex presentation; first posi- 
tion : mechanism and labor normal. Child, female ; weight, 9 pounds 8 
ounces; normal in every way; primary respiration prompt and normal; 
no cyanosis; nursed vigorously when put to the breast. An abundant sup- 
ply of milk appearing on the third day. On the third day at noon the 
child vomited red blood, sufficient in quantity to stain its clothes through 
and through. Shortly after this a very large amount of meconium was 
passed containing red blood, very easily distinguished in the black meconium 
mass. Child pale and blue around the nose, pulse weak and rapid: re- 
fused to nurse after vomiting blood, the nursing being discontinued after 
hemorrhage was reported. 

For five days vomiting of blood and hemorrhage from the bowels oc- 
curred, the latter quite profuse and being passed in masses of clots. 

After treatment with subcutaneous injection of gelatin solution, 2 per 
cent, described below, the cliild made a good recovery: tit the end of the 
second week it had regained its birth weight and continued to thrive. 

Treatment. — Various methods of treatment have been sug- 
gested by different authors. Koplik suggests the cold coil : er- 
gotin, one-half to three-fourths grain subcutaneously : Henoch 
suggests one drop of liquor ferri sesquichloridi in l^arley water 
every hour : AYilliams suggests gallic acid, gr. i, every three 
hours: oil of turpentine, m. i, in mucilage every hour: extract 
of krameria gr. ii, every two or three hours, or an injection into 
the bowel of an infusion 4 to 5 ounces, and calcium chloride 
to increase the coagulability of the blood. 



42 THE DISEASES OF CHILDREN. 

The subcutaneous injection of gelatin employed in the case 
reported was followed by very prompt recovery. 

The English gelatin is used, as the ordinary commercial gelatin 
has been found contaminated with the tetanus bacillus. Two 
sterilizations are made in order to be sure this organism is 
destroyed. An ordinary antitoxin syringe or aspirator, without 
too large a needle can be used for the injection. The cellular 
tissue of the back can be used, the solution warmed, and 20 cc. 
can be slowly injected. 

P. Emile Weil ^ while studying hemophilia began the use of 
fresh animal sera injected either intravenously or subcutaneously 
as a means of controlling or preventing hemorrhage. These ob- 
servations brought out the fact that the serum from horses, rab- 
bits, men and cattle had the power of controlling hemorrhage 
by increasing the coagulability of the blood ; that the serum from 
beef possessed too much toxicity; that the serum should be less 
than two weeks old ; that the dose was 15 to 30 cc. ; it is of 
service locally in causing clotting ; that the increased coagulability 
persisted for a period of from 15 days to several weeks ; that 
sporadic hemophilia and acute purpura gave the most definite 
cures. 

As long as there is any bleeding from the stomach food can- 
not be given in this way, but it can be given by nutrient enemata. 

A case has been very recently under my observation in which 
the hemorrhage was from the bowel alone. On the fourth day a 
very large bloody movement was passed, followed in twenty-four 
hours by six smaller ones. The child showed decided depression, 
pallor, listlessness and crying at intervals, sweating and nursed 
poorly. It had been given two minims of 1 :1000 adrenalin solu- 
tion without effect, and on the second morning shortly after a 
stool containing bright red blood, it was given 7i/^ cc. of normal 
blood serum in the thigh hypodermatically, after which no 
further bleeding occurred. 

UMBILICAL HERNIA. 

Etiology. — The failure of the umbilical ring to firmly unite 
after the cord drops off is the chief cause. Contributory cause 
is the continuous crying of babies subject to colic, hunger, etc., or 

1 Leary: Bostou Medical and Surgical Journal., vol. clix, No. 3. 



DISEASES AND INJURIES OF THE NEW-BORN. 



43 



who strain from constipation. The tumor varies in size from a 
small knuckle to a large protuberance. 

Contents. — The contents of the sac may be omentum alone or 
gut, with or without omentum. 

Treatment. — This is either surgical or palliative. Cures can be 
obtained by the use of an adhesive strip 2 inches wide, and long 




Fig. 7. — Adhesive strap for umbilical hernia. 

enough to reach to the anterior axillary line on each side. The 
hernia is reduced, a pad is made of a button mold, covered with 
adhesive plaster, or of several thicknesses of plaster, and placed 
over the ring. One end of the plaster is applied and drawn over 
the umbilicus, the pad in place, and the skin over the umbilicus 
drawn up into small folds. When the adhesive is changed, which 
should be done every week or ten days, or as often as loosened, 
the finger is placed beneath the pad and held until the new strip 
is applied. 



44 THE DISEASES OF CHILDREN. 

Should the hernia become irreducible, resort should be had to 
surgery at once. 

ATELECTASIS. 

Definition. — This is a condition of the lungs in which all of 
a lobe or a portion of one remains collapsed after birth, the lung 
remaining as in the fetal state. 

Etiology. — The condition .usually follows an attack of as- 
phyxia neonatorum. If the primary wiping out of the mouth 
and nose is not done, mucus may be aspirated and mechanically 
plug up one of the bronchial tubes, permanently closing it, al- 
lowing all lung tissue supplied by it to remain collapsed. Pre- 
maturity is a contributing cause. 

Pathology. — The surface of the lung subject of atelectasis 
shows depressions, corresponding to the undilated portion, with 
air in surrounding tissue. These areas do not crepitate on pres- 
sure and if part of the affected portion is excised it will sink 
in water. Much-dilated bronchioles, areas of compensatory 
emphysema, surround the collapsed portion. 

Symptoms. — Practically the only diagnostic sign of impor- 
tance is the presence of cyanosis with no heart lesion being 
found. The child does not thrive, is bluish in color, especially 
when crying, and the cry is feeble. Convulsions may rarely 
be seen. The physical signs are of little assistance in reaching 
a diagnosis. Owing to the emphysematous areas around the 
atelectasis, no dulness or bronchial breathing can be obtained. 
The respiratory murmur is feeble and slightly harsher than 
normal. 

Treatment. — The principal treatment is that of prevention, by 
attempting to cause the child to take deep inspirations imme- 
diately after birth. The methods of artificial respiration men- 
tioned elsewhere should be employed early. 

ICTERUS. 

Jaundice is present in from one-third to one-half of all new- 
born infants. The depth of the discoloration may be a very 
slight yellow tinge of the skin and conjunctiva, usually classi- 
fied as the (a) Mild Form, and a deep injection of these tissues 
th^ (b) Grave Form. 



DISEASES AND INJURIES OF THE NEW-BORN. 45 

Etiology. — ]\Iany causes have been suggested. Sepsis causing 
a fatty degeneration of the liver has been named as one of the 
principal causes. Changes in the circulation accident to birth 
has also been named. The cause may be mechanical, as a tumor, 
as in the case of suprarenal hemorrhage (page -iO), pressing on 
the gall bladder and ducts. The condition may be hematogenous 
in character. 

Symptoms. — In the miJcl form there may be a slight discolora- 
tion of the conjunctiva and of the skin of the face, chest and 
back, or there may be a deep injection of the skin of the entire 
body, discoloration of the urine and light colored movements. 
These changes usually appear by the end of the first week and 
persist for a week or ten days, with a gradual return to normal 
conditions. The child may be slightly apathetic, nurse poorly 
and sleep more than usual during this time, with a gradual re- 
turn to normal in one or two weeks. 

In the grave form there may be a congenital malformation 
of bile ducts or gall-bladder, with cirrhotic changes in the liver. 
The symptoms are the same as in the mild form save they are 
all intensified; umbilical and other hemorrhages are more often 
seen, and death ensues promptly. 

Treatment. — Saline enemata once or twice daity is of great 
benefit. The ordinary cases usually require no treatment except a 
dose of calomel or castor oil. 

SEPSIS. 

Etiology. — This condition is due to an infection of the new- 
born by one or more of the pus-producing organisms, the strep- 
tococcus or the staphylococcus being the most f recpient form. 
The most favorable site for entrance of the organism is the um- 
bilicus, either before or after the separation of the stump. The 
infecting organism may be carried to this point by the capillary 
action of an infected napkin ; hence the necessity for an antiseptic 
dressing to the umbilicus until the navel has healed. 

The following portals of entry of the organism may be men- 
tioned : Injuries and ahrasio)is, as in a forceps operation, with 
an infection after birth; abrasion of the mucous membrane of 
the mouth; septicemia of the mother during the later weeks 



46 THE DISEASES OF CHILDREN. 

of pregnancy; putrefaction of the liquor mnnii, with ingestion or 
aspiration of this by the child before and during labor; or a 
violent vaginitis and endo cervicitis of the mother before birth 
and infection of child in its progress through the canal; sup- 
puration of the mammary gland during lactation, and an infec- 
tion of a milk duct, with a contamination of the milk, the infec- 
tion being through the gastrointestinal tract ; or an infected 
wound followng clipping of the frenum Jingum in tongue tie 
or following circumcision. 

Systemic Symptoms. — The first evidence of the condition 
usually appears during the first week and may be a failure of 
the child to nurse. If the infection has been at the navel and 
there is peritoneal involvement, or an inflammation of the ves- 
sels under the anterior abdominal wall, there is continuous 
crying, distension of the ai^domen and the child lies with legs 
drawn up. The temperature is high but fluctuating; jaundice 
is present when the liver is involved; pulse rapid and small; 
skin hot and dry, and there may be petechial spots develop or 
large ecchymotic areas, frequently they appear on the part which 
is in contact with pillow and bed. 

Prognosis is very grave. 

Treatment. — Support and nourishment offer the only possible 
hope of relief. If the child is unable to nurse, rectal feeding 
and gavage must be resorted to, using by the former completely 
peptonized milk, and by gavage, breast milk, if it can be 
obtained. 

CASE I. Baby D, born of primiparous mother, after a tedious labor, 
terminated by instrumental delivery, which was easy. No abrasions or 
abnormality noticed. Mother developed sepsis during the first week, with 
temperature to 106° F., on one occasion. Local focus of infection found 
in posterior vaginal culdesac which had sustained a rent in the mucous 
membrane during the delivery. Cephalhematoma over left parietal devel- 
oped on third day; fever began evening of third day, continuous and high, 
often to 104° F. ; hemorrhage from frenum, which was clipped at this 
time; both ears discharging on tenth day; losing weight steadily, gavage; 
catarrhal enteritis; convulsions on fourteenth day; jaundice on twentieth 
day; ecchymoses general, and rigidity of extremities and spine; death on 
twenty-fir^st day. 

CASE II. Tedious labor, terminated by forceps delivery, chihl weigh- 



DISEASES AND INJURIES OF THE NEW-BORN. 47 

ing lYo pounds; normal for tirst three days; temperature of 104:° F. on 
morning of fourth day, which was thought to be due to starvation. Arti- 
ficial feeding reduced temperature to 100.6° F., and it was normal the 
next day. The cord dropped oft' on the fifth day, leaving a moist base. On 
the seventh day the temperature was 104.4° F. ; listless and slow about 
nursing. Pus found in umbilical depression; pain on manipulation of 
abdominal wall, and some distension. Continuous temperature until its 
death, three days later, when it reached 107° F. Just l)efore its deatli 
hands and feet became cold and blue, changing to deep purple, the dis- 
coloration on the lower extremities extending to the hips. 

INJURIES TO THE NEW-BORN. 

As a result of prolonged lalior, pelvic deformities, with instru- 
mental or manual delivery to overcome these conditions, the child 
may sustain fatal injuries, or injuries which may cripple it 
for life. 

High Forceps is a capital operation with very serious results 
in a large percentage of cases. Williams, in 119 collected cases 
of high forceps, found a maternal mortality of 40 per cent 
and an infantile mortality of 60 per cent. 

As a result of forceps operation the following injuries may 
be named : Lacerations of the skin by the blades ; injury to eye, 
especially when a fenestrated blade is applied too far up upon 
the head; facial paralysis; depressed cranial bone, or a frac- 
ture of the bones ; cerebral hemorrhage from rupture of vessels 
in the meninges or brain ; facial paralysis from pressure of the 
tips of the blades on the seventh nerve. 

Version. — ]May result seriously to a living child. Among the 
most freciuent accidents are fractures of the long bones of the 
extremities and the clavicle ; laceration or rupture or hematoma 
of the sternocleidomastoid muscle ; fracture and depression of 
the cranial bones ; rupture of vessels in the meninges or of the 
sinues in the dura; Erb's paralysis from pressure on the 
brachial plexus of nerves ; atelectasis from delayed delivery of 
the after-commg head. 

MASTITIS. 

During the first two weeks after birth the child's breasts fre- 
quently become distended with milk, occurring in either sex. 
The breasts may become tense and painfid to the touch, causing 



48 



THE DISEASES OF CHIT.DREN. 



restlessness and crying. If friction or pressure is used upon 
them, a breaking down of the gland tissue is apt to ensue, or an 
infection follow which results in a severe inflammation, with 
formation of pus. 

Focal Symptoms. — Continued enlargement of the breast, red- 
ness of the skin over it, fluctuation, tenderness on manipulation. 



tayoll 


""- / z i 


) 4^3£:^=:LLijL^4^^T 


i 
c 
c 
2 

«J 
U. 

a 

D 
< 

a 














107 




















106 
















« --^ Sttzt 


^ ^^^=P' 


















104 


■ 




t - - - 




n 




. 






JU)8. _J 








_ n 




T 




T 




102 ^'- 


y\ 


f 


2x 


t 


f T 


t 


M 


_1. 


t 


101 ; 




J 




T 




I 




r 




100 _r_ 


I 




H t 


J 


I 


^ 


4 - X 




It -ft- 1 


oe2_ 


Is _- J ^ _ _ 




^ ^Z I jI 




^ -. ^ ,-► J- -J j\ 




- ^ 




vv 




-. *"' 




-^- 


L97I 1 1 1 I 1 


i^^tf^aaz^^b^^z^Hfi-: 



Fig. 8. — Starvation temperature. 

Prognosis. — If an abscess does not result, the milk is soon 
absorbed and no trouble results, but if an abscess forms, and an 
incision is necessitated, the function of the gland of a female 
may be impaired in later life. 

Under aseptic precautions, in suspected cases, a hypodermic 
needle may be inserted and the contents 'aspirated to learn the 
presence or absence of pus. 



DISEASES AND INJURIES OF THE NEW-BORN. 49 

STARVATION TEMPERATURE. 

The accompanying charts indicate the condition which is fre- 
quently seen during the first few days after birth, the second 
or the third, as a rule, in which there is a rise in temperature, 
which subsides after the administration of an artificial feeding, 
or ■ which will disappear as soon as the milk appears in the 
mother's breast. It is a phenomenon too infrequently noticed, 
as the temperature of but few new-born babies is taken. 

Symptoms. — An apparently perfectly healthy and sound baby 
cries, sucks its fists and tugs at the empty breasts, and is very 
restless ; its skin, mouth and tongue are hot and dry ; and prostra- 
tion begins promptly. The temperature rises quickly and has 
usually reached its maximum in a few hours. 

Treatment. — In the presence of a high fever without other 
definite symptoms the child should be given an artificial feeding, 
if the breasts are not secreting, composed of a weak modified 
milk mixture of a formula approximating the following : Fat, 
1., sugar 6., proteid 0.50, y^ to 1 ounce at a feeding. The tem- 
perature should be taken again in a few hours to ascertain its 
course, and if it is declining the baby should be fed regularly 
until the milk comes. If it will not nurse, gavage may be tried 
with excellent results. 

CEREBRAL HEMORRHAGE. 

The proneness of new-born infants to hemorrhages, has already 
been referred to. Cerebral hemorrhages may arise from the 
vessels in the brain, meninges or dura, may be very small in size 
or consist of large extravasations. They frequently follow a 
tedious or instrumental delivery and deformed pelvis which 
cause undue intracranial pressure. This complication will be 
referred to in another chapter. 

TETANUS. 

Synonyms. — Lockjaw, trismus nascenUnm. 

Etiology. — Tetanus is due to the entrance of the tetanus 
bacillus into the circulation, its toxins exerting their effect 
particularly upon the central nervous system. The bacillus may 
enter at the umbilicus or an abrasion of tlie skin carried tlirouiili 



50 THE DISEASES OF CHILDREN. 

the medium of unclean hands, dressing:s, etc. The principal 
habitat of the bacillus is in the neip^hborhood of stables and 
stable yards, and dust and dirt from this locality may convey 
the infection. 

Pathology. — There may not be any characteristic change in 
the tissues at the point of entrance of the bacillus, or a slight 
inflammatory reaction. The brain and cord may show punc- 
tate hemorrhages or larger extravasations, as a result of the con- 
vulsions. The internal organs are congested and there are ser- 
ous exudates in the ventricles and cord. 

Symptoms. — In a majority of cases the symptoms appear 
during the first week or ten days after birth, though they may 
occur any time before the fourteenth day. It is rare during the 
third week. 

The child may at first be listless and show a disinclination to 
nurse ; there soon follows a spasmodic contraction of the muscles 
of the lower jaw, which very soon becomes fixed and tightly 
closed. It is impossible to push the nipple between the child's 
gums. If liquids are poured into the mouth swallowing is im- 
possible, and the first few drops passing the pharynx may cause 
a reflex spasm of the pharyngeal muscles and a general convul- 
sion. The child has an anxious, frowning look, between the 
spasms, and a more or less general spasmodic contraction of the 
facial muscles during a convulsion. During a general convul- 
sion the respirations are stertorous and between, they are hur- 
ried and superficial. The sphincters of bladder and rectum are 
relaxed and involuntary passages are usual. As the case pro- 
gresses the periods of rest between the convulsions are shorter, 
contractions begin, the spine becomes contracted, arching back- 
ward, the opisthotonos being at times extreme, the child resting 
on head and heels. The temperature is usually very high, 104° 
F. to 106° F. In the latter period a convulsion may be induced 
by touching the child, especially about the face. Feeding is 
impossible. 

Prognosis is very grave, as nearly all cases die. The younger 
the child the more hopeless the case. Escherich reports recov- 
eries. 

Diagnosis. — This is usually easy and must be made from 



DISEASES AND INJURIES OP THE NEW-BORN. 51 

meningitis and from the paralyses and contractions following 
cerebral hemorrhages of the new-born. 

Treatment. — The most favorable results can be had from the 
use of the tetanus antitoxin, which, like the diphtheria anti- 
toxin, gives the best results the earlier it is used. As in adults 
the serum is a better prophylactic agent than a curative one. 
Five to ten cubic centimetres of the antitoxin may be injected, 
and repeated in from six to eight hours. The subcutaneous 
method is recommended, over the injection into the spinal canal, 
owing to the difficulty of performing the latter operation. The 
influence upon the minds of the family of the lumbar puncture 
is very great, and a fatal result of the disease is attributed to 
the puncture by the average layman. 

Prophylaxis is the chief treatment, strict cleanliness in tying 
the cord and its care afterward being an absolute essential. 
Upon the appearance of the symptoms, control the convulsions 
if they are severe, by inhalations of chloroform. Give at once 
the following prescription by rectum, using the small bulb syr- 
inge : 

I^ Strontii bromidi gr. v 

Chloralis hydratis gr, ii 

Aquae distillat 3! 
M ft. Clyster. 

This may be repeated in two or three hours for its effect. 
Gavage should be resorted to with tube introduced through tlie 
nose in those cases in which improvement is noted in the con- 
vulsive stage. 

SCLEREMA. 

Etiology. — This is obscure, being ascribed as due to sepsis, 
persistent fetal circulation; athrepsia, especiallj^ that following 
acute diarrheal diseases and poor nourishment. Two forms are 
described, scleredema or the edematous form, and sclerema adi- 
posum or fat sclerema. 

Pathology. — In scleredema the changes described are an 
edematous deposit in the skin, cellular tissue, muscles ; serum 
in the peritoneal and pleural cavities ; inflammatory conditions 
of the intestines and lungs ; atelectasis ; fatty liver and spleen. 



52 THE DISEASES OF CHILDREN. 

In the form known as sclerema adiposum, there is a hard- 
ening of the tissues, a drying up of the fat in them, the changes 
in the internal organs being much the same as in the other form. 

Symptoms. — In scleredema there is a subnormal temperature, 
with dry, cold skin. The parts first affected are usually the 
calves of the legs, the thighs, abdominal wall and if severe, then 
the rest of the body. The skin may pit on pressure, or in the 
more severe forms be so tense as not to be influenced by pressure. 
If punctured yellowish serum, rather oily, exudes. 

In favorable cases the skin gradually resumes the normal, 
leaving wrinkles over the previously affected parts. Desqua- 
mation usually supervenes. 

In sclerema adiposum the legs are also the first part affected, 
usually symmetrically. It also may involve the whole body, 
except, as a rule, the palmar surfaces of the hands and plantar 
surfaces of the feet. The skin feels doughy, it is closely adher- 
ent to the underlying tissues. The heart is weak and much 
slower than normal, as are the respirations. The temperature 
is usually lower in this form, 92° F. being recorded as having 
been reached. 

Duration is short in both forms, though it is usually much 
more rapidly fatal in the latter form. 

Prognosis is very grave in both forms, though recovery is 
reported in both. 

Treatment. — The first indication is the restoration and main- 
tenance of the body temperature, which can be done by impro- 
vising an incubator. External heat is most important. Stimu- 
lants are necessary, especially whisky and strychnia, 1/200 grain 
of the latter, by the mouth or subcutaneously in a portion of the 
body unaffected. Camphor in olive oil may be given by hypo- 
dermic in very weak heart action with good results. 

External application of cod liver or olive oil, with mild 
massage, is a great help. Gavage may have to be resorted to in 
some cases. 



CHAPTER IV. 

GROWTH AND DEVELOPMENT. 

The average weight for boy babies at birth is about 7i/^ 
pounds, of girls 7 pounds. But few babies weigh as much as 12 




SCALES 
ROLLED 




(Cooke). 



pounds at birth. During the first week after bii'th tlie ehihl 
loses in weight, frequently as much as a pound, but upon the 
advent of the mother's milk the gain in weight is steady and 

53 



54 THE DISEASES OF CHILDREN. 

should be not less than 4 ounces a week. Usually at the end of 
the third week it has more than regained its birthweight. No 
other single method is of such assistance in determining a child's 
progress as its weight, and a pair of scales should be as much a 
part of a nursery outfit as a baby's bed. The platform dial 
scale upon which has been anchored a basket is a very useful 
one, as it weighs in one-quarter pounds, but the platform, arm- 
balance scale is much more accurate. The weighing is best 
done after a bath when the child has been dried ready for dress- 
ing. It is thus weighed without clothes and with an empty 




Fig. 10. — Nursery scales. 

stomach. If the dial scale is used the arrow can be made to 
start at zero by the set-screw on the top after the blanket has 
been placed in the basket; but if the balance scale is used the 
blanket must be accurately weighed and deducted from the gross 
weight. 

As a rule infants which are deprived of normal breast milk 
do not thrive as rapidly as those who are nursed at the breast. 
When a suitable formula of modified milk has been provided the 
gain is then satisfactory. 

"While it is of great service to the physician in estimating 
the progress of a child, to know its weight from week to week, 
this regular weekly weighing may unnecessarily worry a nervous 
mother, and some discretion must be exercised in requesting it. 

The following chart, an average taken from a number of pub- 



GROWTH AND DEVELOPMENT. 



55 



lished records of investigations, gives the growth of the infant 
from birth through childhood. 



Birth 
6 mos. 

12 mos. 

18 mos. 
2yrs. 

3 yrs. 

4 yrs. 

5 3'rs. 

6 yrs. 

7 yrs. 

8 yrs. 

9 yrs. 

10 yrs. 

11 yrs. 

12 yrs. 

13 yrs. 

14 yrs. 

15 vrs. 



(Boys, 
pirls. 
jBoys. 
^ Girls. 
jBoys. 
^ Girls, 
j Boys . 
JGirls. 
]Boys. 
j Girls. 
(Boys, 
j Girls. 
( Boys . 
j Girls. 
( Boys . 
(Girls. 
( Boys . 
) Girls . 
5 Boys, 
j Girls. 
( Boys . 
j Girls. 
^Boys. 
(Girls. 
5 Boys. 
(Girls. 
(Boys. 
( Girls . 
5 Boys. 
(Girls. 
jBoys. 
(Girls. 
\ Boys . 
(Girls. 
jBoys. 
) Girls. 



WEIGHT. 


HEIGHT. 


HEAD 
CIRCUM. 

~Y3^8"' 


CHEST 
BREADTH 


7.47 


20.1 


13.0 


7.13 


19.9 


13.3 


12.4 


16.0 


25.4 


16.5 


16.6 


15.5 


25.0 


16.5 


15.6 


21.2 


29.2 


17.9 


17.9 


20.4 


28.7 


17.9 


18.2 


22.8 


30.0 


18.5 


18.5 


22.0 


29.7 


18.0 


18.2 


28.4 


33.1 


19.1 


19.5 


27.8 


32.7 


18.3 


18.2 


33.5 


36.0 


19.3 


20.1 


31.5 


35.6 


19.0 


19.8 


36.4 


38.6 


19.7 


20.7 


35.1 


38.4 


19.5 


20.5 


41.4 


41.7 


20.3 


21.5 


40.2 


41.3 


19.9 


21.2 


45.1 


44.0 


20.0 


23.2 


43.6 


43.4 


19.8 


22.8 


49.5 


46.1 


20.0 


23.7 


47.8 


45.8 


20.0 


23.3 


54.5 


48.5 


20.5 


24.4 


52.2 


47.8 


20.2 


23.8 


59.8 


50.0 


20.6 


25.1 


57.4 


49.6 


21.2 


24.5 


66.0 


52.0 


20.6 


25.8 


63.0 


51.7 


20.5 


24.7 


71.5 


53.8 


20.8 


27.2 


69.9 


53.8 


20.7 


25.8 


78.8 


55.6 


21.0 


27.5 


80.0 


56.6 


20.9 


26.8 


86.0 


57.8 


21.1 


27.7 


89.9 


58.6 


21.5 


28.5 


97.2 


60.5 


21.3 


28.8 


99.3 


60.3 


21.3 


30.0 


104.1 


62.9 


22.2 


30.5 


107.5 


61.5 


22.0 


31.0 



The suggestion of Holt that a record blank or "progress re- 
port" be printed and given to niotliers when dismissed from 
their puerperium, which are to be filled out and mailed to the 



56 THE DISEASES OF CHILDREN. 

physician at weekly or bi-weekly intervals, is a most excellent 
one. The following chart, a modification of Holt's, is of great 
service in recording the progress of the child; its weight, gain 
or loss ; digestion, disposition, food prescriptions, etc. In the 
card index system it is easily referred to, and a nratter of perma- 
nent record. The last three lines are filled in by the physician 
recording any changes which may be made in food prescriptions, 
if laboratory fed, and the formula if the milk is modified at 
home. 

EEPORT ON PROGEESS OF 

Name Date 19 . . . 

Weight lb oz. Gain oz. Since last report 

Loss oz. 

Stools avg. in 24 hours Color Mucus 

Curds Watery Loose Thick 

Flatulency or cole ? 

Appetite : Is child satisfied ? Is any food left ? . 

Is the child comfortable and good natured? 

How much does he sleep ? 

Date of last report ? 

n F. S. P Cr. % Sk. M M. S 

No feed Interval Dil Aq Aq. C 

Each 5 



The child's first years are usually divided as follows, early 
infancy from birth to the twelfth month ; infancy until the com- 
pletion of dentition, usually about two and a half years, child- 
hood from this time until puberty. 

The measurements of the chest and head are given on page 55. 
It can be noted by reference to the table that at birth the head 
is greater in circumference than the chest; at the third year 
they are about equal, and from this time on the chest is larger. 

The new-born infant should have regained its birthweight 
shortly after the end of the first week ; by the end of the second 
week, gained 2 to 4 ounces; at 16 weeks its birthweight is usu- 
ally doubled, and at one year of age it is usually three times its 
birthweight. 

The most rapid growth of the infant during the first year is 
in its weight. Its increase in length in this period is about 



GROWTH AND DEVELOPMENT. 57 

8 inches, and after this it is at the rate of about 4: inches a year. 

Any serious interference in this ratio, approximately, is an 
evidence of defective nutrition as a rule, and should receive 
prompt and careful attention. Schwartz ^ has suggested the 
following tables for calculating the weight and height at differ- 
ent ages : 

Weight first twelve months. Third to seventh month, add 10 
to the month ; other months add 8 to the month. 

Example: Weight at 4th month? 4+10=14 lbs. 
Weight at 10th month? 10+ 8 = 18 lbs. 

Weight of a child at any age. Multiply the age of the child, 
plus 1, by 5, and add 10; except for the twelfth, thirteenth and 
fourteenth years add 15, 20 and 25, respectively. 

Example: Weight of child at 4 years? 

4+1 = 5 5X5 = 25 25 + 10 =.35 lbs. 
Weight of child at 15th year? 

15 + 1 .=.10 16X5 = 80 80 + 20=100 lbs. 

Height of a child at any age. Up to the sixth year multiply 
the year by 3 and add 26. after the sixth year multiply by 2 and 
add 32. 

Example: Height of child at 4 years? 

4X3 = 12 12 + 26 =. 38 inches. 

DENTITION. 

The process of eruption of the teeth through the gums is den- 
tition. A child may be born with a tooth throug'h the gum, but 
these cases are most rare, and the teeth very soon become loose 
and fall out. The first teeth are the temporary, deciduous or 
milk set, and are composed of two central and two lateral in- 
cisors, two canines and four molars in each jaw. The teeth 
are found in the jaw about the sixth week of intrauterine ex- 
istence. As nutrition proceeds the crown is completed, the root 
hardens and develops, and they are Forced outward tlirough the 
gums. 

The eruption of the teeth is a pliysiological and entirely 



1 New York Medical Journal. 



58 



THE DISEASES OF CHILDREN. 



normal process, and should not be looked upon as the bugbear 
of infancy. It is very easy to state that any pathologic condi- 
tion, especially gastrointestinal disturbances, occurring during 
the first five months, are due to the teeth, and not look to the 
diet, for instance, as a cause of the disturbance. 




Fig. 11. — Temporary and permanent teeth. 

Unquestioned cases of disturbance of digestion, vomiting or 
mild diarrhea ; or mild but persistent cough, are seen during the 
early period of dentition, with more or less prompt relief of 
symptoms when the gum is penetrated by the tooth. Cases in 
which these symptoms are coincident with the eruption of a 
tooth are almost without exception subjects of other disorders, 
principally of nutrition. IMucli delayed dentition is usually due 
to rachitis. There is usually an active development of the 



GROWTH AXD DEVELOPMENT. 59 

salivary glands some weeks before a tooth is cut, and there is a 
constant escape of saliva from the mouth dnrino- the waking 
hours. The child may be more restless than usual, and bite upon 
everything it can grasp with its hand. 

It is in those cases which show some nervous symptoms and 
restlessness or which present some of the other symptoms enu- 
merated, that the most benefit is had from making an incision 
through the gums. This does not retard the eruption of the 
teeth through the scar tissue which may form over the tooth, but 
relieves the tension and swelling of the gums and many or all of 
the symptoms. The child is held upon the lap of the nurse, 
who sits facing the operator. The child sits with its back to the 
operator, and with the nurse holding its hands its head is lowered 
between the knees of the operator and there held. With one 
hand holding open the gums and retracting the lip, the incision 
is made directly over the teeth with the other. It is generally 
not necessary to lance the gums over the molars, as they usually 
erupt one sharp prong at a time and without symptoms or diffi- 
culty. The first deciduous teeth to fall out are the upper central 
incisors, as a rule, the permanent teeth very shortly afterward 
coming in. The first milk teeth are lost usually at the end of 
the sixth year, the 20 occupying the site of these and are fol- 
lowed by the molars. The teeth usually appear as follows : 

Two lower central incisors, six to nine months. 

Four upper incisors, seven to ten months. 

Two lower lateral incisors, 12 to 14 months. 

Two anterior upper molars"^ ^^ ^^ ,, . 

^ ^ . 1 1 ^ 12 to 16 months. 

1 wo anterior lower molars J 

Two upper canines (eve teeth) 1 -,n . o« ^i 

m 1 • \\ T. + +1 r 18 to 24 months. 

Two lower canmes (stomach teeth J 

Tavo upper posterior molars^ ^, , „^ ,, 

, , . , h 24 to 30 months. 

1 wo lower posterior molars J 

The permanent teeth usually are cut as follows : 

Four first molars, six years. 

Four central incisors, seven years. 

Four lateral incisors, eight years. 

Four bicuspids, eight and one-half to nine years. 

Four bicuspids, ten years. 



60 THE DISEASES OF CHILDREN. 

Four canines, 11 years. 
Pour second molars, 12 to 13 years. 
Four wisdom teeth, 18 to 25 years. 

An attack of acute illness, just at the time of the dentition, 
may seriously impair the life of the tooth. 

CASE. Mother nursing infant of three months developed a severe 
typhoid fever. Baby removed at once and put on modified milk. In ten 
days or two weeks afterward child developed a typical attack of typhoid 
fever, which ran a mild but usual course. Very soon after the subsidence 
of the fever she cut her first teeth. She rapidly began to gain in weight, 
but a black line developed on the upper central incisors. This deepened 
and finally the teeth broke oflF through the line, short with the gums, and 
no other teeth have displaced them, though the child is now four years 
of age. 

The deciduous or temporary teeth should be cared for with 
the same routine as the permanent set. They should be brushed 
twice daily with a soft tooth-brush or cotton mop, and regularly 
inspected by a competent dentist for any imperfections indi- 
cating softening. Nothing so completely upsets the nervous 
equilibrium of a child as the toothache, and should always be 
prevented. 

Timely and proper removal of the deciduous teeth may pre- 
vent erratic cutting of the permanent teeth, which later will 
have to be straightened. Thumb and finger sucking, and the 
pernicious use of the ' ' comforter, ' ' or rubber nipple, as a quieter 
or pacifier, is a frequent cause of deformities of the arch and dis- 
placement of the teeth. 

Hutchinson's teeth are due to congenital syphilis. The upper 
central incisors are peg shaped and notched, with irregular 
ragged surfaces. 

MENSTRUATION. 

Menstruation usually begins in this climate })etween the thir- 
teenth and fifteentii years of age. In 17-1 girls, inmates of the 
Masonic Widows' and Orphans' Home, the following were the 
ages recorded for the beginning of menstruation : 



GROWTH AND DEVELOPMENT. 61 

1 1 3 ears 2 

12 years 18 

13 years 47 

14 years 71 

15 years 33 

16 years 3 

174 

It was usual for these children to menstruate once, perhaps 
twice, then miss for several months, and begin again and with 
regularity. Very frequently one month, occasionally two 
months, were skipped in a year, without apparent cause. No 
special season was noted for this to occur. AVhen more than 
three months were missed after regular periods had become 
established, attention was given, and a few weeks' tonic treat- 
ment usually resulted in its re-establishment. 



CHAPTER V. 

METHODS OF EXAMINATION. 

Physical examination in pediatries is our chief diagnostic aid, 
and all of the known methods should be employed: inspection, 
palpation, auscultation, mensuration and percussion, chemical 




Fig. 12. — 1, Axillary region; 2, Infra-axillary region. 

analyses of secretions and excretions, and microscopic examina- 
tion of serum, blood, excretions and exudates, etc. The value of 
the information obtained from mother and nurse should not be 
minimized, but one should not be influenced by misleading and 
irrelevant statements. 

62 



METHODS OF EXAMINATION. 



63 



A child sliould always be carefully inspected as it lies, espe- 
cially if asleep ; its position ; color ; respiration, character and 
frequency ; dilatation of the alae nasi ; temperature of hands and 
feet. 

Diplomacy yields best returns in a physician's interview with 
a child. If you once obtain its confidence the rest is easy. The 
child may be nervous, cross and irritable ; will cry when touched ; 
it mav be almost vicious in its resistance to examination. Each 




Fig. 13. — 1, Supra-clavicular; 2, Cla- 
vicular ; 3, Infra-clavicular ; 4, Mam- 
marj ; 5, Hypochoudriac ; 6, Epigas- 
— i,. : 7, Stprnal; 8, Umbilical; 9, 
Hypochondriac. 




Fig. 14. — Posterior Regions of Ciiesi— 
1, Inter-scapular; 2, Supra-scapular 
?. Scapular; 4, Infra-scapular; 5 
Lumbar. 



child is an individual, and no method of approach will suffice in 
two successive eases. 

Too much emphasis cannot be laid on the importance of care- 
ful history taking and recording- the findings in every case. 
This is best done on suitable blanks which can be filled out at 
the bedside, and filed in card index systems. A daily resume 
of symptoms and treatment are recorded and filed Avith the first 
chart. Previous illness, dentition, food, bowels, and the symp- 
toms and course of present illness are carefully recorded, and 



64 THE DISEASES OF CHILDREN, 

a daily record blank used afterward in connection with the 
case. A blank used by the author for the first history is shown 
here: 



Name . . 
Add . . . 
Ser. To 



Prem ( Duration Cond. birtli 



r Vigorous 



Born Term Labor ] Instrument j ., , 

I (^ C onvuls 



Wt. at birth Breast fed Diet since , 



Wt 

Teeth Ist 

Crept Walked 

Measles Pertussis Scarlat Diphth Grip .... 

Tonsil Otitis Croup Bronch Pneumon 

Nervous sys Sleep Adenoids . . 



Note the child as it awakens, whether bright, quiet, peevish or 
crying; size of its pupils, color of skin, etc. A child cries for 
some cause as a rule. Kilmer gives the following 11 causes for 
a child 's crying : 

1, because it is hungry; 2, because it is in pain; 3, because it 
is thirsty ; 4, because it wants attention ; 5, it is sleepy ; 6, its 
napkin is wet ; 7, it is tired lying in one position ; 8, it is fright- 
ened ; 9, it is exhausted ; 10, it is crying from temper ; 11, it is 
uncomfortable, clothes wrinkled, etc. It must be remembered 
that a normal healthy child does not cry from choice. 

Inspection should include a personal view of the napkins, es- 
pecially if there has been any variation from normal in the evac- 
uations. No description by nurse or mother is adequate to con- 
vey the real character of an action. 

It should be determined whether the sight of the child is 
normal or impaired, if the pupils are equal, contracted, dilated 
or fixed. The presence of nystagmus, or side to side movements 
of the eyeball is noted. If the child is able to be up, the char- 
acter of the gait should be noted. The reflexes also should be 
noted. The chief one is the knee reflex, obtained by tapping the 
tendon below the patella while supporting the thigh and allow- 
ing the leg to hang naturally. 



METHODS OF EXAMINATION. bD 

Kernig-'s Sign. — The child lying upon its back with thigh 
flexed half way upon the abdomen, the leg partly flexed on the 
thigh, the leg cannot be extended. 

Babinski's Reflex. — AVith leg extended and slight irritation 
of the plantar surface of the foot the great toe is fully extended, 
and the other toes partly flexed. This reflex is noted specially 




Fig. 15. — Position for taking rectal temperature. 

in tubercular meningitis, though authorities differ as to its value 
as a diagnostic sign. 

Sach's Sign of Chorea. — The child, standing before the exam- 
iner, is asked to repeat a certain sentence, and in the effort to 
do so there is a decided tremor of the hands, which are held in 
those of the examiner. 

The cry of a child is usually characteristic. In cerebral affec- 
tions the cry is shrill and sudden ; in affections of the larynx it 
is hoarse, brassy, strident; with middle ear inflammations it is 
continuous and shrill and accompanied with pidling at the ear 



66 THE DISEASES OF CHILDREN. 

affected; in colic the child cries loudly and intermittently, and 
continuously flexes and extends its legs and thighs. 

Temperature. — As already stated the temperature of the child 
during the first year is usually between 99° and 99.5° F. An 
infant's temperature should always be taken in the rectum. If 
the mother has a thermometer hers should be used, and if not 
the physician should carry two, one for use in the rectum only. 
The child may be held upon the nurse's lap lying upon its 
abdomen, legs hanging down. With napkin off; the thermom- 
eter, well anointed, is carefully passed into the rectum and 
allowed to remain for two minutes. Half-minute thermometers 
are not reliable. The child may be placed upon its side, on the 
nurse's lap or in bed, with thighs flexed, but under no circum- 
stances should the thermometer be inserted in the rectum with 
the child lying on its back with legs and thighs flexed, as it may 
raise the hips from the bed and break the thermometer. 

After taking the temperature the thermometer should be care- 
fully washed with soap and water and placed in alcohol for a 
moment. I have had some success with the clean shield rubber 
covering to the thermometer, which is thrown away as soon as 
used. The possibility of transmission of infection in girl babies 
of vulvovaginitis should be borne in mind. Groin or axillary 
temperature in a child is always unreliable. 

I saw a child in consultation, ill with pneumonia, and from 
the extent of the consolidation was surprised at the temperature 
recorded being 102.5° F., it having been taken in the axilla. I 
requested it taken in the rectum and found it 105° F., which 
was more in keeping with the other symptoms. 

Another case recently occurred in which the rectal tempera- 
ture in a suspected typhoid was recorded as 97° F., with every 
indication of fever. A change of thermometers showed it to 
be 102° F. Examination of the first one revealed the fact that 
it was not self -registering, the mercury falling into the bulb as 
soon as it was removed from the rectum. These things must 
be borne in mind. 

The throat of every sick child should be carefully inspected. 
The child is held facing a strong natural or artificial light, with 
back to the right shoulder of the nurse, who holds the child's 



METHODS OF EXAMINATION. 



67 



hands. The examiner with his left hand holds the head and 
with the right depresses the tongue Avith spoon or tongue de- 
pressor, and a quick view of the fauces, tonsils and uvula is 
obtained. Young infants are usually not frightened by a head 
mirror, though older children may be unless its use is explained 
to them. Owing to the fact that the tongue is high in infants 








Fig. 16. — Examination of throat by direct illumination. Note position of nurse's 
hands, holding patient's head and hands. 



and the soft palate and tonsils relatively low down, it is oc- 
casionally difficult, in them, to get a good view of the throat. 

The importance of this examination cannot be too forcibly 
emphasized, as frequently severe attacks of diphtheria may de- 
velop without any pain or discomfort or inability to swallow 
being complained of. The use of the wooden tongue depressor, 
which is thrown away after using, is recommended instead of 
metal tongue depressor or spoon. 

The mucous membrane of the mouth, cheeks and lips should 
be inspected for the presence of the huccal eruption of measles 



68 



THE DISEASES OF CHILDREN. 



(Koplik), which is referred to under another chapter, or for 
the presence of ulcers or deposit of thrush or sprue. 

The tongue is inspected and its general condition noted; 




Fig. 17. — Tongue depressor handle with removable wooden depressors. 

whether the frenum linguse is short and inhibits the range of 
motion; if it is dry, coated, flabby, and shows the imprint of 
the teeth; if it presents the characteristics of the strawberry- 
tongue of scarlet fever, or if ulcers are present at any place on its 
surface. 

Examination of the middle ear is a procedure too frequently 




oOO 

I 2 3 

Fig. 18. — Ear specula. 

neglected by the practitioner. Many cases of unexplained fever 
of some duration in children can be cleared up by an inspection 
of the drum membrane. A bulging congested drum means 
middle ear trouble. An inspection is made through a small 
size ear speculum (the lobe of the ear being drawn down, as 
suggested by Dr. Jas. F. McKernon of New York), by reflected 



METHODS OF EXAMINATION, 69 

light from a head mirror. The child is held in the nurse's lap, 
the unaffected side against the breast of the nurse, her hand 
supporting the head and with the child's arms and hands, held 
by a sheet, wrapped around the body. With the light behind 
the nurse's head, and unobstructed view of the canal and the 
drum can be had by reflected light. 

The nose should receive attention, as much may be found 
here to cause discomfort if not symptoms. The child is sup- 
ported much as for a throat examination, with chin elevated 
and a good view of the entrance to each nostril obtained. 

Hypertrophied turbinates frequently encroach on the space 
of the nostril, especially when there is an acute coryza. Con- 
cretions of dried discharge also" may have to be removed before 
a view can be had. Anointing with vaseline, by means of a 
cotton-protected swab, gives great comfort in these cases. The 
habit of older children of putting foreign bodies, as shoe but- 
tons, beans, etc., in the nostril and ears should be borne in mind. 
I recently removed a foot of a small china doll from the nose 
of a two-year-old child, experiencing some difficulty in getting 
a firm hold of it with a forceps. 

The slxin should be carefully examined for eruptions, and at 
this time the child's clothes must be entirely removed. Enlarge- 
ment of the superficial glands must be looked for, axillary, post- 
cervical, submaxillary, epitrochlear and inguinal. 

Palpation, — By palpation of the head the condition of the 
fontanelles can be ascertained, craniotabes located, if present, 
and enlarged glands in the occipital and pvstcervical region 
found. Palpation of the chest with a warm hand on each side 
of the anterior surface, then the posterior should be done to as- 
certain presence or absence of ronchi or rattles. 

The ribs should be examined for beading and the epiphyses 
of the long bones for enlargement. The lower abdomen and 
inguinal region should be palpated for hernia, and the scrotum 
for hydrocele, hernia or undescended testicle. 

The frequency of the heart beat can be determined by palpa- 
tion of the apex beat, or feeling the pulse at the wrist, temple, 
groin or ankle. Its character can best be learned by palpation 
of the radial artery at the wrist. The frequency of the heart 



70 THE DISEASES OF CHILDREN. 

can also be determined by auscultation over the apex, or inspec- 
tion of the precordial region. 

The abdomen should be carefully palpated to ascertain the 
presence of tumors or marked glandular enlargement; the mus- 
cle guard over an inflamed appendix; an enlarged liver or 
spleen. An enlarged liver may be determined also by percus- 
sion, but an enlarged spleen only by palpation. The presence of 
underlying distended intestine prevents percussion from being 
of value in investigating the spleen. An enlarged kidney may 
be diagnosed by abdominal palpation. 

Rectal palpation is of great service in diagnosticating sus- 




Fig. 19. — Bowles stethoscope with small chest piece. 

pected cases of intussusception. This should be done with the 
utmost gentleness. Inspection of the rectum for fissure should be 
made whenever a child cries with the passage of his movements, 
especially if there is any blood with the action. 

With patient on a table, lying on its face, the spine is in- 
spected and palpated. If local bone changes (Pott's disease) 
are suspected the examination includes an effort to locate rigid- 
ity. 

Auscultation of the chest is the most important aid to diag- 
nosis of diseases located there. 

A complete auscultation of the chest cannot be made without 
the aid of a stethoscope, either the binaural, bell stethoscope 
with small chest piece, or the Bowles stethoscope with the small 
chest piece. The child should be held so high that the examiner 
does not have to bend over, thus compressing his abdominal 
vessels, and causing a flushing of the face and ringing in the 
ears. It may either be held on the nurse's shoulder for exam- 
ination of the back, or face down upon the nurse's lap. Auscul- 
tation of the axillary region in a child with the ear is impossible. 
I have seen one case of deep-seated pneumonia with only one 
spot the size of a 25-cent piece showing bronchial breathing, and 



METHODS OF EXAMINATION. 



71 



this was located in the extreme upper portion of the axilla where 
the ear could not possibly have been placed. Then, too, the ear 
covers too much space and it is impossible to localize a small 
area of consolidation. 

As the auscultation is proceeded with comparison should be 




Fig. 20. — Position for auscultation of back. 

made of the two sides at exactly corresponding points. It should 
be remembered that the child's chest wall is thin and is a better 
conductor of sound than an adult 's, the bronchial tissue is greater 
in proportion than the vesicular, hence the respiratory sounds, 
especially expiration, will be much higher-pitched than the 
adult's. In fact, when listening to a child's lungs, it is well to 
forget the sounds in an adult's chest, they are so different. 

The sound over the upper third of the sternum and along the 
second and third interspaces is quite bronchial in character, es- 



72 



THE DISEASES OF CHILDREN. 



pecially on the right side, because of the larger size of the right 
primary bronchus and its angle at this point, allowing a larger 
volume of air to enter this side. This is true also over the inter- 
scapular spaces. 

Auscultation of the heart should be systematic, listening over 




Fig. 21. — Auscultation of chest. Comfortable position. Bowles stethoscope. 

the apex, the base, and right second intercostal space, and if 
murmurs are present they should be traced and located. 

Percussion. — Percussion over the chest may be performed 
with the finger as the pleximeter, and a percussion hammer, or 
with the index and second fingers of one hand as the hammer. 
The pleximeter finger should be placed the same on each side, if 
on the second rib on one side it must be similarly placed on the 
other, to obtain a comparison of sound. In percussing over the 
posterior wall, the presence of the liver on the right side under 
the ninth rib must be remembered, and not mistake the absence 
of resonance for consolidation or exudate in the pleural cavity. 
The area of dulness over the heart can be easily determined by 
superficial percussion. On deep percussion in this area, there 



METHODS OF EXAMINATION. 73 

is apt to be transmitted resonance from underlying lung tissue. 

Mensuration. — This is a valuable aid in diagnosis. A tape 
on a spring in a case which will roll up on pressing a release 
button is most satisfactory. The metal tape bearing the metric 
measurements on one side and English on the other is a very 
serviceable one, but the greatest objection is the chill which it 
causes when brought in contact with the skin. 

In hydrothorax or pneumohydrothorax, the tape is of the 
greatest service in estimating the amount of effusion. In en- 
largement of the joints it is an assistance, also in ascertaining the 



Fig. 22. — Stanton's percussion hammer. 

presence or absence of shortening of the lower extremities, and 
of atrophy following infantile paralysis particularly. In mak- 
ing this measurement the comparison of the two sides is taken 
from the anterior superior spinous processes of the ilium and 
the internal malleolus of the tibia. The measurement from the 
umbilicus as the fixed point is relative only. 

A useful tape in comparing the expansion of the two sides 
is made by sewing together two tapes at 1 inch end, this junction 
being held upon the spine as deep inspiration is taken. 

The comparative measurement of the head and chest is of 
value also. The circumference of the head is taken around 
the middle of the forehead and over the parietal bosses, and 
around the nipples for the chest. 

Measurement of the height of the child should be regularly 
made and recorded to ascertain if its growth is progressive and 
regular. 



CHAPTER YI. 

THERAPEUTICS OF INFANCY AND CHILDHOOD. 

There should always be a clear indication for medication in 
children, and no remedy employed without the indication is 
present. Children respond readily to therapeutic measures, and 
this should be borne in mind in dosage. 

Young's method of figuring the dose of a given medicine for 
a child is as follows: Add 12 to the age of the child and divide 
the age by this sum, which will give the proportionate quantity 
of the adult dose. 

Example: If the age of the child is two years: 

2 -f 12 = 14 2 (the age of the chiki) h- 14 = 2/^^ or 
y^l the adult dose. 

Cowling's Rule. — Divide the age of the child at its following 
birthday by 24, the result being the proportionate adult dose for 
the child. 

Example: If the child is two years old, 2 ^ 24 = %4 or 1/^2 the 
adult dose. 

No medicine should be given a child under three years of 
age, in pill form, owing to the possibility of the pill being aspi- 
rated into a bronchus. It is a good plan to teach children to 
swallow pills by making a mass of bread, as much that is disa- 
greeable to the taste can be administered in this form. 

Powders are not well taken by children, and should either be 
dissolved or suspended in a watery solution or in an emulsion. 
If a powder is given dry it is very apt to gag the child as it gets 
in the mouth or some of it may be aspirated into the larynx and 
cause violent coughing. 

Enemata are as a rule well borne. If nutrient, they should 
be given half high and never in very large quantities. Two 

74 




THERAPEUTICS OF INFANCY AND CHILDHOOD. 75 

ounces is as much as will be taken care of as a rule, and they 
should not be repeated too frequently. Nutrient enemas should 
be predigested as the bowel at this point will absorb but not 
digest. Owing to the loose mesentery of the sigmoid flexure, 
and the relative greater length of this portion of the bowel a 
child requires a larger quantity of fluid for purposes of evacua- 
tion than is usually given. The pressure of the fluid in the bag 
should not be very great, the bag not being more than 3 feet 
above the patient. The Davidson 
syringe should never be used on an 
infant. It is impossible to keep 
this kind of syringe clean, and one 
cannot gauge the amount of pres- 
sure exerted on the resistent bowel. 
The use of the high, copious enema 
for the purpose of reducing an intussusception is a remedy 
which if used at all should be used with the greatest caution. 

Suppositories are efficient and, if not too large or too often 
repeated, can be used as a means of medication or to evacuate 
the bowel. For the latter purpose the long glycerine pencil 
is very practical and very efficient. In writing a prescription 
for a suppository directions should always be given that they 
be small. 

Inhalation. — In older children much good can be accom- 
plished by a croup kettle or steam atomizer. The small steam 
atomizer is placed at the side of the bed and a sheet so arranged 
as to cover three sides of the bed; in this way the child con- 
stantly breathes moist air, which can be either with or Avithout 
a medicament. Benzoin is a very soothing remedy and may 
be added to the water in the atomizer. 

In older children the irLbalation can be given by making a 
paper cornucopia to the top of a pitcher or Mason jar holding 
hot water. The face is held over this and deep inhalations taken 
of the plain or medicated vapor. 

In spasmodic croup, or true croup (diphtheria), especially 
when a tube is worn in tlie latter, the moist air is of the great- 
est lielp. 

Gargles.— May be employed in oldei' ('hildriJii wlieii inilicated. 



76 THE DISEASES OP CHILDREN. 

A child has to be taught to gargle, as a rule, and usually in a 
few attempts will succeed. 

Hypodermoclysis. — In certain conditions where there is a 
septic condition or a marked collapse from any acute or wasting 
disease, this method of treatment yields excellent results. 
Enterocylsis, referred to elsewhere, especially by the continuous 
method, is of great service also. 

In hypodermoclysis, a normal salt solution, approximately 
one teaspoonful of salt to a pint of distilled or filtered water, 
is injected into the cellular tissue of the skin. These injections 
should be at a temperature of 100° F., and in quantities not 
to exceed 40 to 50 cc. at a time. Careful sterilization of the 
needles and apparatus, and of the skin should be obtained. It 
can be given with a fountain syringe, or a large antitoxin 
syringe, such as were formerly used for the injection of diph- 
theria antitoxin. 

Calomel Vapor Inhalations. — A tent is made in the same way 
as for steam medication, the steam started and 10 grains of 
calomel sublimed in the tent, its fumes being added to the steam. 
The calomel can be heated in a spoon held over a candle or 
alcohol lamp, or in specially devised sublimers. This form of 
treatment was used formerly more frequently than of late, espe- 
cially in diphtheria affecting the larynx. 

Medicinal Antipyretics should be used in children with 
great caution, this being specially true of the coal-tar products, 
antipyrine, acetanilid, antifebrine and phenacetine. Children 
bear hydrotherapeutic measures very well indeed, and these 
should be used to the exclusion of the medicinal antipyretics in 
all forms of hyperpyrexia. If it is necessary to give them, the 
use of caffeine at the same time is advocated. 

Stimulants are well borne as a rule, alcohol in some form; 
strychnia, nitroglycerine, sparteine, digitalis, all ])eing well 
borne by children. Alcohol in certain conditions is the best 
form of stimulant, as in the crisis of lobar pneumonia, late in 
typhoid fever, diphtheria and the exanthemata. It should be 
well diluted, at least 1 to 6 or 8 parts of water, and if whisky 
is used, a good straight, bottled in bond, article should be in- 
sisted upon. Do not begin the use of alcohol in the beginning 



THERAPEUTICS OF INFANCY AND CHILDHOOD. 77 

of any illness and not at all until there is a positive indication 
for it. It may, under conditions where the stomach will not 
retain it, be given by the rectum, but in larger quantities and 
the same dilution. Brandy will often be tolerated when 
whisky will not. 

Camphor is a diffusible stimulant, and may be used by hypo- 
dermic injection in olive oil, } or 1 grain in 20 drops of olive 
oil. 

Anodynes. — Children are peculiarly susceptible to anodynes, 
and they should be given with great caution. Opium, in any 
form, should never be given mixed with other drugs in a pre- 
scription. It can be given at the same time, but added to the 
mixture at the time of giving. In this way a relatively large 
dose can be given as a rule. Chloral is also well borne and can 
be given by the stomach or bowel. 

Counter Irritants are easy of application owing to the deli- 
cateness of the child's skin. Mustard, turpentine, chloroform, 
in the form of sinapisms or liniments ; iodine must be used with 
caution to guard against blistering. Blisters are easily raised 
when desired by cantharides in form of plaster or collodion. 

Weak mustard plasters in my hands have been of greater 
service than a strong mixture. One part of mustard to 6 or 
8 parts of flour is very efficient and soothing. In bronchitis, 
bronchopneumonia, pleurisy and intercostal neuralgia the appli- 
cation of a mustard plaster is of the greatest efficiency. 

The Bath. — The bath is a most important and useful means 
of combating certain symptoms in children. It is the most 
important antipyretic measure, and if children are early taught 
to enjoy the bath and are not frightened by being plunged into 
too cold water, it will always be a pleasure to them to be bathed. 

A bath thermometer should be a part of the equipment of 
every nursery, and the temperature of the water accurately 
taken. Do not use the child as thermometer, ''if the water is 
too cold the skin turning blue, and if too hot the skin turning 
red." When used as an antipyretic the water should at first 
be about 95° F. and cooled to 75° F. or 80° F., according to 
its effect on the child. The tub should be large enough to allow 
the child to recline, its head supported by the arm of the mother 



78 



THE DISEASES OP CHILDREN". 



or nurse. If the bath is given in a porcelain tub, a bath towel 
is laid on the bottom so the child will not slip about, or the 
cold tub be disagreeable. Cold water or ice water is added at 
one end of the tub, away from the child, and the water thor- 
oughly mixed. The child is gently rubbed, legs and arms, back 




Fig. 1^4. — Collapsible rul)l)ei- bath tub. 



and chest, during the entire time it is in the water. If the 
teeth begin to chatter and the child to shiver, the bath should 
not be prolonged. No hard and fast rule can be given as to 
the duration of the bath, as children react so differently. An 
average duration of ten minutes is the proper length of a bath 
for its antipyretic effect. 

Should a child object to the bath from fright, it can be low- 
ered into the water in' a sheet stretched across the tub, the water 
gradually covering the body. 

The rectal temperature should be taken just before the bath 
and 30 minutes afterward. If the child still feels hot when 
it is removed from the water and is dried, increased radiation 
can be accomplished by rubbing with a weak solution of alcohol, 
1 tablespoonful to 6 ounces of water, allowing this to evaporate, 
the sponging being continued for five or ten minutes. 

A preliminary bath before the physician arrives in the pres- 
ence of temperature above 103° F. is always indicated, and 



THERAPEUTICS OP INPANCY AND CHILDHOOD. 79 

mothers should be told to do this without further instructions. 

In older children the regular bath should be a delight instead 
of a bugbear. In those who are susceptible to "colds," a cool 
bath, or the cool sponge, of the chest and back following a warm 
bath each morning, this followed by a brisk rub, is of the 
greatest benefit. With some children the spinal douche of cold 
water can be employed, but not very frequently. Some chil- 
dren prefer a cool bath, always. I have two boys under my 
observation, aged 4 years and 18 months, who have a daily bath 
in water between 55° F. and 60° F., and object to a tempera- 
ture even as high as 70° F. 

In hot weather, a second bath at night before retiring gives 
great comfort and insures a good night's rest. 

Bran Bath. — Two teacupfuls of bran, in a cheese-cloth bag, 
to enough water in the tub to cover the child's legs when 
sitting in the water, is of great service in itching, irritated, skin, 
due to urticaria and prickly heat. The water is splashed on 
the body and the skin is not rubbed. The temperature of the 
water should be below 80° F. On removal from the tub the 
skin is quickly dried with soft towels, without friction, and 
the surface freely powdered with talcum. 

Soda Bath. — In urticaria, especially, a general soda bath gives 
much comfort, or a basin bath may be used, the solution being 
' ' sopped ' ' on with soft gauze or washcloth. If a general bath is 
given use a half teacup ful of the bicarbonate of soda to the 
quantity of water used for the bran bath, or a tablespoonful of 
the soda to a pint of water for the basin bath. This is allowed 
to dry on the skin naturally. 

Mustard Bath. — For pulmonary affections the mustard bath 
is of the greatest service. It can be used with benefit also with 
children in convulsions, or very nervous and irritable ones. Two 
heaping tablespoonfuls of Coleman's powdered mustard are dis- 
solved in five gallons of water, through a cloth or gauze, in 
order to prevent its floating on the surface, and sticking to the 
sides of the tub. Care should be exercised to prevent the child 
rubbing its eyes with its hands, wet with the mustard water. 
The mustard bath is given at a temperature of from 95° F. to 
100° F., and can be cooled to 85° F., just before child is re- 



80 THE DISEASES OF CHILDREN. 

moved. The child is rubbed vigorously between blankets and 
put in bed at once after being dried. 

Brine Bath. — In feeble and poorly-nourished children the salt 
or brine bath can be used with benefit, as it acts as a tonic and, as 
a rule, an excellent reaction is obtained. Ordinary salt, or if it 
can be obtained, sea-salt, can be used, one or two tablespoonfuls 
to the gallon of water. A basin bath with soap and water can 
first be given, and the child then put in the salt water, the skin 
being rubbed constantly for the five or ten minutes it is kept in 
the water. The reaction from this bath is usually greater than 
from any other form. 

Nauheim Baths. — The artificial Nauheim-Schott treatment ^ 
consists in the use of brine baths, with or without free carbonic 
dioxid. Their object is to enable a dilated heart, that is unable 
to expel its contents, to empty itself completely. 

Briefly, the effects of the baths are obtained by the tempera- 
ture, duration and amount of salts and gas contained in them. 

The average temperature to begin with, is 92.7° F., the re- 
duction not more than 2.2° F., the duration usually not longer 
than 10 minutes. The minimum temperature of any bath is 
81.5° F., the maximum duration of 20 minutes. 

Commercial bicarbonate of sodium and crude hydrochloric 
acid (42 per cent) are added in equal quantities by weight to 
the bath water. In the beginning one-fifth of a pound of each 
is added to 62 gallons of water, this quantity gradually in- 
creased to three pounds of each. The bicarbonate of soda is 
first dissolved and poured into the bath water and the acid 
added when everything else is ready. It is added by pouring it 
along the bottom of the tub under the water. The layer of car- 
bon dioxid formed on top is removed by fanning, the window 
being open. 

Wet Cool Pack. — As an antipyretic measure this is probably 
the best, and one which is infrequently used by the profession 
as a rule. It can be used with a child at any age, and may be 
continued for long periods at a time, 10, 12, or as in a case 
reported by Kerley, for 72 hours. The bed is protected by a 
rubber sheet, which is covered with a draw sheet. The child 



1 Nothnagle's Encyclopedia — Diseases of the Heart. 



THERAPEUTICS OF INFANCY AND CHILDHOOD. 81 

is then stripped, its legs being covered by a blanket. A large 
bath towel is used in preference to a sheet. This envelopes the 
child's chest, and is pinned loosely enough to go over the shoul- 
ders, like a baby's pin blanket, leaving the arms free and ex- 
tending down as far as the middle of the thighs. With bath 
thermometer in the basin of water at the bedside, the tempera- 
ture of the water is carefully watched. The rectal temperature 
of the child is taken at half -hour intervals in order to learn the 
rapidity of the fall. The pack is first put on dry. 

The towel is wet thoroughly with water at 90° F. or 95° F., in 
order not to shock the child, the water being put on the towel 
from a piece of gauze which is squeezed on it, the child turned 
in order to have the back wet. In five or ten minutes the w^ater 
is cooled 5° F., and the towel again wet in the same way. A 
child with a temperature of 105° F. quickly dries the towel. It 
is the aim to keep it wet constantly. Each time the towel is wet 
the water is cooled until it reaches 70° F. Heat to the feet and 
cold to the head is a great assistance. An ice bag may be laid 
against the head or cold cloths applied to the forehead and vertex. 
The pack is removed when the temperature is reduced to 102° F. 
This treatment is indicated in all forms of pyrexia, from 
whatever cause. Pneumonia, the exanthemata, typhoid fever, 
etc. The presence of a rash is no contraindication, though some 
difficulty may be experienced in some families to convince anx- 
ious mothers and friends that it will not ' ' drive in the rash. ' ' 

Mustard Plaster. — If properly applied, a mustard plaster is 
of the greatest benefit in certain conditions of the respiratory 
tract, and where counter irritation for any reason is desired. 
The plaster made at home is more effective and less disagreeable 
than the mustard leaves on the market. If the skin is delicate 
and irritable, 1 part of the mustard to 8 or 10 parts of flour 
will be found very serviceable. The mustard flour and the wheat 
flour are made into a thick paste with cold water and spread 
between two thin pieces of cloth, warmed before the fire and 
placed upon the skin. The plaster is allowed to remain on the 
skin until it is reddened, which can be ascertained by lifting up 
the corner of the plaster. After removal the skin is greased 
with vaseline, and when the skin has resumed the normal hue 



82 THE DISEASES OF CHILDREN. 

the plaster can be renewed, a fresh one being made each time. 
Irrigation of the Nose. — The child is placed on the nurse's 
lap or on the bed, lying upon its side, its head slightly lower 
than its body. The child can be held upright, sitting on the 
nurse's lap, its head bent slightly forward over a basin. With 
either a fountain syringe or glass syringe, with a rubber tip, 
the solution, warmed to 90° F., is put into the upper nostril 



^ ^'If=^ ..... i 



Fig. 25. — Glass syringe. Soft rubber tip. 

and allowed to run out of the lower nares. The child may have 
to be wrapped in a sheet to confine its arms and legs, if it resists 
the operation very much. 

Stomach Washing.^ — Epstein of Prague, in 1880, recom- 
mended washing the stomach in certain diseases of the gastro- 
intestinal tract. Dr. A. Seibert of New York, in 1888, advo- 
cated its use, and since then lavage has been extensively used. 

The apparatus used is a No. 13, American scale, soft rubber 
catheter, not too flexible, about 12 inches in length. This is 
attached to a piece of rubber tubing 2 feet long, with a short 
piece of glass tubing between. A glass or hard-rubber funnel 
of 2 or 3 ounces capacity is attached to the free end of the 
rubber tubing. 

Plain lukewarm water previously boiled is the only fluid 
which should be used, and as a rule 1 pint is all that is necessary. 

The child is seated upright in the nurse's lap, head against 
her right shoulder. A rubber apron is pinned around the child 's 
neck, its lower end, long enough to reach the floor, in a basin 
or bucket, in front of the nurse's feet. The child's hands are 
held by one of the nurse's hands, its legs by the other. The 
child's tongue is depressed by the left forefinger, and taking 
advantage of the gagging the tube is rapidly pushed down the 
esophagus to the stomach. The tube is wet before being intro- 
duced and no lubrication is needed. 

Some gas may be in the stomach and fill the tube, which will 
obstruct the inflow of the first water poured in the funnel, or 

1 "Stomach Washing in Infants," Tuley, Medical News, July 1, 1893. 



THERAPEUTICS OF INFANCY AND CHILDHOOD. 



83 



which is less usual, a curd or bit of mucus may clog the eye 
of the catheter for a few moments. Filling the funnel and 
elevating it to the fullest extent usually causes the water to 
flow in. Through the glass tubing the flow of the water can 
be seen. 

Over-distendino* the stomach with water causes the child to 




\pparatiis for stomach washing. 



vomit alongside the tube, and frequently thick leathery curds 
are ejected which could not have readily been disintegrated. 

The water is siphoned out as soon as a proper amount has 
been allowed to run in and the process repeated until the wash 
water returns clear. 

In removing the tube it should be grasped firmly in order to 
prevent a few drops falling into the larynx as the tip of the 
catheter passes over the epiglottis. 

After the washing, the stomach should be kept entirely at 
rest, and only the easiest digested food administered. Epstein 
suggested the administration of egg allmmcn watcn- for 24 hours 
after a stomach washing:. 



84 



THE DISEASES OF CHILDREN. 



Irrigation of the Colon. — This is a measure frequently abused 
and improperly applied, yet one which is of great benefit when 
properly used. It has been suggested as an antipyretic measure, 
but this should be done with great caution. The indications 
for colon irrigation are referred to elsewhere. 

A No. 14, American scale, soft rubber, velvet-eye catheter, 
or a No. 17, American scale, rectal tube with opening in the 




Fig. 27. — Colon irrigation. Nurse's lap protected by rubber sheet-. 

end, is attached to the small tip of a 2 quart fountain syringe. 
The solution and its temperature should be determined by the 
indications to be met. The syringe is held not more than 3 
feet above the patient, and the first of the water in the tube 
allowed to escape so it will run in an even temperature. 

The child is held either on the nurse's lap, which is protected 
by a rubber sheet, or on a bed, close to the edge, on its back 
or left side with hips elevated, and clothes drawn well up under 
its shoulders. A napkin can be pinned loosely around its waist 



THERAPEUTICS OP INFANCY AND CPIILDHOOD. 85 

and allowed to hang; loose over the rubber sheet. A receptacle 
of some kind is placed nnder the rubber sheet to catch the 
return water. 

The tube or catheter is anointed thoroughly with vaseline, and 
also the anus, as this will make it much easier to introduce the 
tube. After the tube has been inserted 1 or 2 inches the com- 
pression is removed from the tube, and as the water floAvs in 
it dilates the colon ahead of the tube, making- its insertion easy 
as a rule. If straining occurs, the tube is compressed for a 
moment until the spasmodic condition is relieved. If a too 
flexible tube is used, as the tip meets a fold of bow^el, it is apt 
to be bent on itself and forced out at the anus during straining. 

The continuous irrigation already referred to is a measure 
of the greatest benefit in conditions such as sepsis, and failure 
of elimination by the kidney. The hips are slightly elevated 
and a medium-size catheter is introduced half way into 
the bowel. The bag is elevated not more than 12 inches above the 
hips, and enough compression used on the tube to cause the 
water to escape in drops, at a rate so that an average of a pint 
wdll escape an hour. The temperature of the water is kept at 
100° ¥., by the addition of hot water from time to time as it 
cools. 

Collection of Urine for Examination. — Unfortunately the 
chemical examination of the urine of children is very often 
neglected, or even entirely omitted by the average practitioner, 
and probably no other method of diagnosis is of greater impor- 
tance to the clinician. In very young babies it is often a very 
difficult thing to obtain a specimen, especially girl babies, and 
a most useful device has been suggested by Dr. Chapin,^ which 
he describes as follows : 

It consists of a circular opening ending in a funnel that fits in a collect- 
ing vessel. Two sizes have been found necessary, small and large, desig- 
nated respectively as No. 1 and No. 2, for infants under and over one year. 
The urinal is fixed in place by putting the large opening around the vulva 
in the female, and over the parts in the male, with the funnel pointed 
downward. Tapes are put through the openings in the arms and fixed by 
tying around the abdomen and both groins. To fix more firmly in place, 
strips of adhesive plaster may be pasted over the arms. The end of the 



^American Pediatric Society. (Archives of Pediatrics, May, 1906), 



86 THE DISEASES OF CHILDREN. 

funnel is placed in a collecting bottle which is kept in position by the 
diaper. If the baby is very restless, a cork may be put in the end of 
the funnel and the bottle dispensed with, as enough will often be thus 
collected for examination. 

If the child is too ill to be held over a vessel at intervals, if 
a rubber napkin is put on with a small pledget of cotton at 
the nates, some urine will soon be caught, enough for a chem- 
ical aind microscopical test. It should be borne in mind that 
any powder used about the vulva may contaminate the urine. 

As an example may be mentioned the case of pyelitis referred 
to elsewhere. The urine from this patient was submitted to an 
expert clinical pathologist who found pus and albumen in the 
urine and also an object under the microscope resembling the 
egg of an intestinal parasite. It was finally remembered that 
lycopodium was used with talcum powder with this child, and 
these objects were the seed pods of the lycopodium. 

Inunction. — The skin can be used for introducing medicines 
into the system, though it is a very uncertain method. In 
athreptic and marasmic children some absorption of fat can be 
obtained by inunction, and by enveloping the child in cotton 
soaked with oil, mercury can be introduced through the skin 
by rubbing the ointment into the flexures, using these alternately. 



CHAPTER VII. 

INFANT FEEDING. 

Infant Feeding. — All forms of food contain essentially the 
same ingredients viz., proteids, fats, carbohydrates, mineral mat- 
ter and water. From conception until about one year after 
birth, the supply of nourishment Is obtained from the mother. 
By this time the infant's digestive tract is developed sufficiently 
for it to care for soft food and exist independently of the mother. 

Breast Feeding". — No substitute has ever been found for nor- 
mal mother's milk for the nourishment of the infant. Mother's 
milk contains the food elements, fat, sugar, proteid, mineral water 
and salts, in the proportions best suited for its digestive capacity 
and nutrition. The infant should be put to the breast as soon as 
the mother has had a rest from her labor, as the colostrum, pres- 
ent in the breast before labor, is essential for its purgative effect 
on the child. During the first 24 hours the child should be 
nursed every six hours ; during the second 24 hours, every four 
hours ; during the third 24 hours, every three hours ; during 
the fourth 24 hours, every two hours. The milk usually comes 
the evening of the second or the morning of the third day, after 
which time the nursing should be every two hours. If nursed 
every two hours during the first three days the tugging and 
pulling on a flabby, empty breast results in an erosion or fissured 
nipple. 

A cracked, fissured or eroded nipple is a most painful and 
distressing condition, as well as a dangerous one from the pos- 
sibility of an infection of the breast occurring through this open 
wound. A fissured or eroded nipple should not be nursed from 
directly, but protected by a nipple shield. The glass shield with 
rubber nipple and guard is the most serviceable, and if filled with 
warm water when applied to the breast will encourage the child 
to pull when the nipple is placed in its mouth. Immediately 
after each nursing the nipple should be painted with a solution 

87 



88 



THE DISEASES OF CHILDREN. 



of nitrate of silver, 20 grains to the ounce of water, care being 
taken to limit the application directly to the affected part. This 
forms a pellicle from the coagulated albumen of the serum, and 
allows granulation to occur beneath it. The nipple is then cov- 
ered with a piece of sterile gauze or soft linen. 

After the milk comes, the nursing should be by schedule, 
every two hours during the day and every three hours at night : 
From 6 a. m to 10 p. m. every two hours, and one or two 
nursings at night. Under no conditions should a baby be 
allowed to sleep with its mother; the danger of over-laying is 
great, as is the danger of the child nursing most of the night. 
This always results seriously to the child's digestion. 

Schedule for nursing a breast-fed baby : 



AGE. 



First three days 

Until end of first month. . 
Second and third months. 
Fourth and fifth months . . 
Sixth to twelfth months. . 





NUMBER NIGHT 


NUMBER OF 


INTERVAL DAY. 


NURSINGS. 


NURSINGS 24 HR 


4 to 6 


1 


4 to 6 


2 


2 


10 


2* 


1 


8 


3 


1 


7 


3 





6 



The child should nurse from one breast at each nursing, 
alternately, and should be satisfied in from 10 to 15 minutes. 
If it must be nursed from both breasts each time, and is unsat- 
isfied when the nursing is finished, the quantity is inadequate 
for its needs. By regularity being established early both the 
baby is trained to good habits, and the breasts to secrete at 
regular intervals. 

The nipples should be washed before and after nursing with a 
solution of boracic acid, and the child's mouth thoroughly 
cleansed before and after the nursing with the same solution. 

It should be a rule to give water to a nursing baby between 
feedings. Before the milk comes, in order to prevent a too rapid 
loss of weight, there should be given at regular intervals a 2 per 
cent solution of sugar of milk, or even plain sterile water. 

There are but few contraindications to maternal nursing. A 
severely inverted nipple makes it impossible for the child to 
nurse. Nursing should not be allowed in mothers suffering 



INFANT FEEDING. 89 

from tuberculosis in any form ; malignant disease ; diphtheria ; 
rheumatism or chorea ; acute contagious diseases and pneu- 
monia : erysipelas; albuminuria; typhoid fever, as the typhoid 
bacillus is excreted in the breast milk ; the acute exanthemata ; 
pregnancy occurring during lactation ; epilepsy or nephritis, or 
if the mother has suffered from puerperal hemorrhage, nephritis, 
eclampsia or infection. 

Nursing Mother. — A nursing mother should lead a perfectly 
normal, healthy life. Her diet should be generous and varied. 
There are practically no articles of diet which, if they agree 
with the mother, will cause the milk to disagree with the child. 

During the first three days of the puerperium the diet should 
be light and easily digested. The following sample diet list 
for the first few days will generally yield good results : 



First day (after labor) : 

Breakfast — Cup of tea, or cocoa; piece of dry or buttered toast. 

Lunch — Beef, chicken or mutton broth; toast or wafer. 

Supper — Glass of milk, or cup of tea. 
Second day: 

Breakfast — Cereal and cream with cocoa or tea. 

Lunch — Soft-boiled egg, rice and cream. 

Supper — Milk toast, tea or milk. 
Third day: 

Breakfast — Soft boiled egg, cereal, coffee or milk. 

Lunch — Baked potato, gelatin jelly and cream, and milk. 

Supper — Baked apple and cream or milk toast. 
Fourth day (after bowels have moved) : 

Breakfast — Cereal, poached egg on toast, breakfast bacon, and cocoa 
or milk. 

Lunch — Squab or bird, potato chips or baked potato; cocoa. 

Supper — Mush and milk. 
Fifth day: 

Breakfast — Cereal, broiled steak, hashed brown or baked potato: 
milk. 

Lunch — Chicken, broiled or baked; mashed potatoes, sweet potatoes, 
asparagus tip salad. 

Supper — Milk toast. 
Sixth day: 

Breakfast — Lamb chop, soft boiled or poached egg, toast, cocoa and 
milk. 

Lunch — Junket, cocoa, spinach, potato. 



90 THE DISEASES OF CHILDREN. 

Supper — Baked apple or prune*, toast and milk. 
Bran muffins made of bran and floui-, equal parts, aie i'spccially usefu! 
during this period as a prevention of constipation. 

Strict attention should be paid to her bowels, and at least one 
evacuation had daily. It must be remembered, however, that 
there are a few purgatives which are excreted through the milk. 
I have frequently noticed a purgative effect on the child when 
the mother had been taking cascara in some form. She must 
have at least a half hour's exercise in the open air daily and 
longer, if possible. 

If the child is satisfied after nursing and during the interval ; 
is gaining in weight regularly; is happy and bright; it may be 
asserted the milk is both up to the standard in quantity and 
quality. If the child is satisfied but a short while after nursing, 
soon shows signs of hunger and the supply apparently adequate, 
then it is deficient in quality. If a milk is normal in amount, 
but deficient in certain ingredients, it can often be corrected 
and made to agree with the child. 

The Method of Nursing. — Primipara should be instructed in 
the proper method of putting the child to the breast and holding 
it while nursing. During the puerperium, the mother lying 
partly on her side, the baby is put to the breast so it can readily 
grasp the nipple, which has been previously prepared, and one 
finger depresses the gland so that it will not press upon the 
nose and interfere with its breathing. The baby can either be 
supported upon the arm or lie flat upon the bed, the mother's 
arm being raised. 

Holding the breast so as not to obstruct the child's breathing 
is most important. I know of one normal baby when 12 hours 
old entirely asphyxiated from being allowed to bury its nose 
in the breast. 

When able to sit up to nurse, the mother occupies a low 
chair with a footstool, upon which rests the foot of the side 
from which the baby nurses. The baby is held upon the arm, 
and the mother leaning forward slightly places the nipple 
squarely, not obliquely, in mouth. 

Breast Milk. — Breast milk is more bluish-white than yellow, 
and has been shown by Kerley and others to be faintly acid 



INFANT FEEDING. 



91 



when tested with 1 per cent alcoholic solution of phenolphthalein. 
By others it is claimed breast milk is amphoteric, that is, it is 
alkaline to red litmus and acid to blue litmus. 



li'iiiiiiiii lillPlii 



CD 

GD"F 

5aD-p 

35D^ 



25D 
2DD 

lOD-g 



|5D-^ |5D- 

-Holt's milk set. 



rt 

GC 
GD7 

450-S 

350^ 

3QD 
250-^ 

IzddI 

I5D 

IDO 

sn ■ 



Fig. 28.- 

The following table is given by Holt, showing 
tion of breast milk : 



the composi- 



Average Common healthy variations 



Per cent. 

Fat 4.00 

Sugar 7.00 

Proteids 1.50 

Salts 0.20 

Water 87.30 ' 



Per cent. 



3.00 to 
6.00 to 
1.00 to 
0.18 to 
89.82 to 



100.00 



100.00 



5.00 
7.00 
2.25 
0.25 
85.50 

100.00 



Milk must be thought of as a homogeneous mixture, its chief 
ingredients being fat, sugar and proteids, and the percentages 
of these must be definite and stable if the milk will agree with 
the child. The usually accepted analysis of mother's milk 
shows, fat 3.5 per cent, sugar 6 per cent, proteids 1.5 per cent. 

An examination of breast milk by means of the Holt clinical 
milk set will show a more or less wide variation in the proteid 
and fat content in the ^ame individual at different times of the 
day. There is always wider variation in these constituents than 



92 THE DISEASES OF CHILDREN. 

in the sugar, which is more or less constant. As already stated, 
the quantity of the milk may be sufficient for the child's needs, 
but the quality much below. The quantity obtained at a feed- 
ing can be determined by weighing the child before and after 
nursing, as was done in a number of cases by the writer, which 
were reported in the Archives of Pediatrics (May, 1893). 

Each baby was weighed with all of its clothes on before and 
directly after each nursing, with the nurse's and mother's assist- 
ance, being sure that the baby was kept awake during the entire 
20 minutes it was allowed to nurse. The weighing was care- 
fully done upon one of Fairbanks' scales which registered in 
half ounces with no change being made in clothing between 
weighings. Elimination of error was by this means made pos- 
sible which might occur from loss in weight by excrement from 
the child or from a difference in the texture of the napkins ap- 
plied. Eight babies were weighed, 64 weighings being recorded. 
The babies were from two to ten days of age, healthy, and all 
weighing 6 pounds or more at birth. 









Aver, weight of 


Age 


'Number- 


of 


ingested milk 


Days 


Weighings 


Ounces 


2 


2 




1.25 


3 


13 




1.3 


4 


3 




1.0 


5 


10 




1.5 


6 


6 




1.25 


7 


13 




2.27 


8 


6 




2.25 


9 


8 




2.5 


10 


3 




2.5 



Given a case in which there was but little gain after a week 's 
nursing or in which there is continued colic or curds passed in 
large quantities, the breast milk should be examined. This may 
be done clinically by Holt's Milk Set, or chemically, for an accu- 
rate estimate of the fat, proteid and sugar content, or by the 
use of the pioscope. The Babcock test may be made for the 
estimate of the fat content, which when taken in connection with 
the specific gravity will give a fairly accurate idea of the quality 
of milk. 



INFANT FEEDING. 



93 



The child should be put to the breast and allowed to nurse 
for three minutes, and a half ounce of milk either pressed or 
pumped from the breast, and if enough cannot be obtained from 
one side the other is treated in the same way. 

Holt's directions for the use of his milk set are as follows: 

The simplest method is by the cream-gauge. Although its results are 
only approximate, they are in most cases sufficiently accurate for clinical 
purposes. The tube is filled to the zero mark with freshly drawn milk, 
which stands at room-temperature for twenty-four hours, when the per- 
centage of cream is read off. The ratio of this to the fat is approximately 
five to three; thus 5 per cent cream indicates 3 per cent fat, etc. 

Sugar. The proportion of sugar is so nearly constant that it may be 
ignored in clinical examination. 

Proteids. We have no simple method for determining clinically the 
amount of proteids. If we regard the sugar and salts as constant, or so 
nearly so as not to affect the specific gravity, we may form an approximate 
idea of the proteids from a knowledge of the specific gravity and the per- 
centage of fat. We may thus determine whether they are greatly in excess 
or very low, which, after all, is the important thing. The specific gravity 
will then vary directly with the proportion of proteids, and inversely with 
the proportion of fat, i. e., high proteids, high specific gravity; high fat, 
low specific gravity. The application of this principle will be seen by 
reference to the accompanying table. 

woman's milk. 





SPECIFIC GRAVITY, 


CREAM, 


PROTEID 




70° F. 


24 HRS. 


CALCULATED. 


Average 


1.031 


7 per cent 


1.5 per cent 


Normal variations. . . 


1.028-1.029 


8 per cent-12 


Normal ( rich 






per cent 


milk) 


Normal variations... 


1.032 


5 per cent-6 


Normal (fair 






per cent 


milk) 


Abnormal variations . 


Low (below 1.028) 


High (above 10 


Normal (or 


' 




per cent) 


slightly be- 
low) 


Abnormal variations. 


Low (below 1.028) 


Low ( below 5 


Very low 






per cent) 


( vei-y poor 
milk) 


Abnormal variations . 


High (above 1.032) 


High 


Very high 
( very rich 
milk) 


Abnormal variations. 


High (above 1.032) 


Low 


Normal ( or 
nearly so) 



94 THE DISEASES OF CHILDREN. 

Any specimen taken for examination should be either the middle portion 
of the milk, i.e., after nursing two or three minutes — or, better, the entire 
quantity from one breast, since the composition of the milk will differ very 
much according to the time when it is drawn. The first milk is slightly 
richer in proteids and much poorer in fat. 

The "pioscope" is an instrument used for testing breast milk. 
It is composed of two disks, the lower one of hard rubber, the 
upper one of glass. The latter is divided into sections labeled 
and colored to represent milk of different qualities, normal, very 
fat, cream, very poor, poor, less fat. The milk immediately 
after being drawn from the breast is placed in a small depression 
in the center of the rubber disc. The glass is then placed over it 
and as the milk is spread out, the cjuality of the milk can be 
read by comparing with the sections on the glass disc. 

The problems to be met in the supervision of breast feeding 
are : 1. The increase of a too small supply. 2. Changing the 
character of the milk, (a) decreasing the proteids, (b) increas- 
ing the fat, (c) decreasing the fat. 3. To make serviceable 
nipples out of flat and depressed ones. 4. To supply an arti- 
ficial or adjuvant food in case of a good but too small supply 
from the breast. 5. To continue nursing should there be a 
suppurating mastitis, and retain the integrity of the gland after 
a subsidence of the inflammation. 

While, as a general rule, it may be stated the ideal food is a 
healthy breast milk, this is not always the case, for not infre- 
quently a mother has an abundant supply but secretes a milk 
which is unsuited to the needs of her own baby. These cases, 
however, are the exception, and it is infrequent that we find an 
unsuitable breast milk which cannot be changed by suitable 
remedial measures, hence I cannot refrain from saying a word 
against the unnatural mother who refuses to nurse her infant 
from purely selfish reasons, that she may have more time for 
society or pleasure. No physician should be a party to this or 
encourage it in any way, unless it can be plainly shown by most 
careful examination that the milk is unsuited and beyond reme- 
dial measures. The very fact that artificially fed infants show 
so much greater rate of mortality than the breast-fed infant, is 
sufficient reason for advocating breast feeding. 



INFANT FEEDING. 95 

While it may be a fact in the larger centers of population 
that mothers are unfeeling and unnatural enough to allow social 
obligations to interfere Avith nursing their babies, we believe that 
in the South and West this is seldom seen. There are undoubt- 
edly cases where weaning must be decided upon, in which the 
child does not gain, or there is continual disagreement of the 
milk in spite of efforts to change the constituents. I have seen a 
number of cases in which the necessity for weaning has arisen 
early from insurmountable reasons. These have been enough 
to impress on me the folly of voluntarily surrendering a good 
breast milk supply for the uncertainties of artificial feeding. 

It is entirely possible to combine the food elements present 
in milk of the lower animals in the exact chemical proportions as 
in mother's milk, but there is lacking that fine adjustment of 
digestibility found in the milk of the mother. 

The following analyses are given of colostrum : 

TT^ / n slow Pfeiffer 

Fat 4.00 2.04 

Sugar 1.5 3.74 

Proteids 14.8 5.71 

Salts . 1.00 0.25 

Water 78.7 88.23 



100.00 100.00 

Colostrum is more yellow in color than milk, does not coagu- 
late readily except on boiling and contains, in addition to the 
small regular size fat globules, the large granular colostrum 
corpuscles. These may persist in the milk until after the second 
week, but usually are not present after the tenth day. They 
recur during lactation, during menstruation and under the stress 
of great mental excitement, fear, anger, sorrow, sexual excite- 
ment, etc. When present abnormally, similar symptoms appear 
to those which occur soon after birth, diarrhea, and frequently 
vomiting. Compared with milk, colostrum has a higher per- 
centage of proteids and less sugar and fat. 

Besides this change which occurs, the milk may be influenced 
by any temporary illness of the mother, as influenza or grippe ; 
or any serious or prolonged illness, as typhoid fever, which 
would interrupt the nursing entirely. 



96 THE DISEASES OF CHILDREN. 

Certain drugs are said to be excreted in breast milk; as 
opium, belladonna, cascara, mercury, iodides, bromides and 
salicylates. The elimination of drugs in the milk is not suffi- 
ciently certain or exact to employ this method of medication 
in infants, nor enough to remove the child from the breast for, 
if any of these drugs were indicated in the mother. 

The following case illustrates- colostrum disagreement : 

A mother began to menstruate four weeks after her delivery. 
Immediately her baby, which was doing well previously, began 
vomiting and purging. The second month the menstruation 
recurred with similar symptoms in the baby. I was called to 
see the child at this time and an examination of the breast 
milk showed it to be heavily loaded with colostrum corpuscles. 
The child was ill for several days, was weaned, and for one 
year was a constant care and anxiety, because of the difficulty 
of finding a suitable food or milk modification for it. 

There may be ample supply of good milk, but the absence of 
a serviceable nipple may prevent the child's obtaining it. This 
may be often seen, and it should be a routine practice to make 
as early an examination of the breasts and nipples of a preg- 
nant woman as possible, especially in primipara, in order to 
give instructions in the massage of flat and depressed nipples. 
By massage and training a very serviceable nipple can be made 
from an unpromising one if the treatment is begun early enough. 
The wearing of tight corsets or clothing should be advised against 
during pregnancy, but especially in the presence of flat or de- 
pressed nipples. A careful inquiry should also be made of 
multipara in regard to their lactation history, as having a bear- 
ing on the possibility of nursing the new baby. 

The nipples during the last two months of pregnancy, should 
be prepared for nursing after the method of Mabbott. Each 
evening a small bit of lanolin is rubbed into the nipple and sur- 
rounding areola, and as part of the toilet in the morning, with a 
coarse wash cloth and soap they are washed, dried and dusted 
with talcum. 

A stationary weight, or a loss after the second week; vomit- 
ing, not simply a slight regurgitation; colic; continuous crying; 
diarrhea, with green movements, containing curds and mucus, 



INFANT FEEDING. 97 

should be an indication for a close investigation of the breast 
milk, the frequency and time of nursing and the daily routine 
of the baby's life. 

A too high percentage of proteids is evidenced by colic, cry- 
ing, with a doubling up of the legs, tense abdomen, green stools 
containing mucus and curds. This very often occurs during 
the puerperium, but as soon as the mother gets up and is able to 
take the proper exercise, the increased proportion of proteids is 
generally decreased. Should this relatively high percentage of 
proteids with low percentage of fat persist, and the plentiful 
supply keep up, much help can be had from pumping or milking 
out the foremilk from the breast, the child being allowed to nurse 
only the middlemilk and strippings. Taking the child from 
the breast before it has finished nursing and giving it a small 
quantity of barley water, previously dextrinized, from a bottle, 
will often relieve the colic, lessen the diarrhea and make the 
curds smaller. 

Too much fat, which I have met but a few times, causes 
vomiting and diarrhea, with few or no curds in the movements. 
If too much fat is present there may be found in the stools 
small, round masses which resemble casein curds very much, 
but are smooth and soft and not so white as casein curds. 

A too small milk supply calls for active treatment. It is 
evidenced by a stationary weight or a loss in the weight of the 
infant; crying within a few minutes after leaving the breast 
and sucking vigorously on its fists after nursing. If the de- 
ficiency in supply is the only fault, it may freciuenth^ be in- 
creased by such galactagogues as nutrolactis or somatose, free 
drinking of milk, cocoa or chocolate and the cereal gruels. 

These gruels may be made of oatmeal, barley or cornmeal. 
After thorough cooking for several hours, they are ready to 
serve, enough milk being added so they can be drank from a 
cup or eaten with a spoon. No article of diet so stimulates the 
function of the gland as cow's milk, and in connection with the 
cereals excellent results are seen. 

Alcoholic beverages are to be avoided, as they encourage the 
secretion of a milk with a deficiency in its life-giving properties 
and an increase in the watery element. 



98 THE DISEASES OF CHILDREN. 

If these measures do not correct the difficulty, the child should 
be kept on a modified cow's milk, of suitable formula, in addi- 
tion to the nursing, giving at first 1 or 2 drachms to an infant 
of four weeks immediately after a breast feeding, gradually in- 
creasing the amount as indicated. This will generally suffice 
to obtain a satisfactory gain in its weight. 

With a good milk supply, regularity of nursing, infrequent 
or no night nursing, a child will generally do well ; a good supply 
with a disregard of these requisites will result, perhaps, in seri- 
ous digestive derangements. Should a combined breast and arti- 
ficial feeding be necessary, the one or two night feedings should 
be breast milk if for no other reason than the convenience to 
the parents. The only objection to this is the possibility of 
the mother falling asleep and allowing the child to lie with the 
nipple in its mouth for several hours at a time. 

To increase the quantity of the milk, give more nutritious 
diet, more milk and cereal gruels. 

To increase fat, give milk and meat. 

To decrease fat, give less meat and milk and increase the 
water. 

To increase the proteids, give more meat and eggs; lessen 
exercise. 

To decrease proteids, increase exercise to point of fatigue and 
decrease meat. 

Wet Nurse. — In premature infants with no maternal milk 
supply, or where sudden weaning from any cause becomes im- 
perative, a wet nurse should be obtained. 

The selection of a wet nurse is beset with many difficulties. 
The following should be taken under consideration : the age of 
the wet nurse, the age and weight of her infant, the nurse 's gen- 
eral health, development and general surroundings. A careful 
physical examination should be made of both the nurse and her 
baby and tuberculosis and syphilis positively excluded. If there 
is time her breast milk should be carefully analyzed before she 
is engaged. The diet of the nurse should not vary greatly from 
what she has been accustomed to, as lack of exercise may change 
the character of her milk entirely. 



INFANT FEEDING. 99 

Weaning. — It is well to begin weaning an infant at about 8 
months of age ; with at first one feeding a day, then two, gradu- 
ally displacing the nursings by an additional bottle feeding, un- 
til at the end of the first year entire weaning has been accom- 
plished. 

The weaning may be accomplished suddenly, but frequently 
not without considerable gastric and intestinal disturbance being 
caused in the child. 

Combined Feeding. — If it is apparent that a child is not gain- 
ing rapidly while nursed exclusively, by giving one or two arti- 
ficial feedings a day, of modified cow's milk, very good results 
can frequently be obtained. 

As when entire artificial feeding is begun, so when only par- 
tially fed, a much weaker formula should be given than neces- 
sary for the child's needs to begin with, and gradually increase 
the strength of the formula until one is reached upon which it 
will be contented, and will gain in weight. 

It is frequently a very good plan when a child is a few weeks 
old to give it one bottle a day, in order to accustom it to an arti- 
ficial food, and also to enable the mother to have a few extra 
hours of recreation, occasionally, if the demand arises. 

Artificial or Substitute Feeding. — A mother being unable to 
nurse her infant, and a wet nurse is nowhere to be found, the 
child must be nourished artificially. Infants can not be fed 
by rule ; each is a law unto itself ; what will agree with one will 
disagree with another. Adapted or modified cow's milk offers 
the best results, but the first principle to be learned is that one 
must think in percentages, not in standard formulae which can 
be given to this or that baby of a certain age. The minimum 
food requirements must be combined in a scientific adaptation, 
and the proper adjustment made later, sufficient to cause regular 
gains in weight. With careful daily weighing, and inquiry^ 
into the condition of the digestion, a gaining formula will soon 
be decided upon. 

One Cow's Milk. — It has long since become an accepted fact 
that the milk from one cow should not be used for infant feed- 
ing. Mixed milk from a herd is more uniform in composition, 



100 THE DISEASES OF CHILDREN. 

and there is less likelihood of changes occurring in the milk as 
the result of fright, or disease being harmful because of its dilu- 
tion with the herd's milk. 

Cow's Milk. — Because of the universal supply of cow's milk, 
and the fact that it contains the same general constituents of 
and can be modified to nearly resemble mother's milk, it is the 
best substitute for normal mother 's milk, when artificial feeding 
is necessary. A comparative analysis of mother's and cow's 
milk is here given: 

Mother's Cow's 

Milk Milk 

Fat 4.0 4.0 

Sugar 7.0 4.0 

Proteids 1.5 3.5 to 4.0 

No food product is so capable of contamination as milk, or as 
little average intelligence used as in its production and care. 
How common is the saying, especially in cities, when the diet 
of a sick child is under discussion: ''Take it to the country 
where you know good milk can be obtained." It is a fact that 
but few people in the country, unless in the scientific dairy busi- 
ness, know the first principles of the production and handling of 
milk. 

Certified Milk. — Realizing this fact, and that pure milk, espe- 
cially^ for infants, sick children and invalids, was a necessity, 
Dr. Henry L. Coit of Newark, N. J., in 1894, suggested the plan 
of securing a dairyman who would produce milk and handle it 
in a scientific manner, according to the rules of a financially 
disinterested commission of physicians. 

This was done, and the product of this dairy was termed 
"Certified Milk," the term being registered at the Patent Office 
in Washington by the dairyman, Mr. Stephen Francisco, and 
Dr. Coit. They have very generously allowed the use of the term 
by similar commissions, and a number of the larger cities have 
such a supply. In 1907, at Atlantic City, was formed the Ameri- 
can Association of Medical Milk Commissions, with Dr. Coit as 
its first president, its membership composed of the members of 
milk commissions throughout the country, and dairy scientists 
in this country and abroad. This association has done much 



INFANT FEEDING. 



101 



toward systematizing and i^iaking more uniform the rules and 
standards and working methods of commissions and populariz- 




Fig. 29. — Where cleanliness is a religion. Certified Dairy No. 2, Louisville. 

ing this plan of obtaining at least one pure supply of milk in the 
larger centers of population. 

Kentucky has a law which limits the use of the term "Certified 
Milk" to a milk commission regularly appointed by a eount}^ 
medical society. This effectually prevents the use of the term 
by a dairyman, for commercial reasons, without producing the 
milk according to the requirements of a commission. New York 



102 



THE DISEASES OF CHILDREN. 



and New Jersey also have such a law. The Kentucky law is as 
follows: 

An act for preventing the manufactmiiig and sale of adulterated or mis- 




Fig. 29a. — Immaculate milking conditions. Certified Dairy No. 2.^ 

branded foods, drugs, medicines and liquors, and providing penalties for 
violations thereof. 

Be it enacted by the General Assembly of the Commonwealth of Kentucky: 
Section 1. That it shall be unlawful for any person, persons, firm or 
corporation within this State to manufacture for sale, produce for sale, ex- 
pose for sale, have in his or their possession for sale or to sell any article 



1 Figs. 29 and 29a from "Certified Milk Production" by the ;iutlior, i)ublislied 
in The Milk Trade Journal, June, 1913. 



INFANT FEEDING. 103 

of food or drug which is adulterated or misbranded within the meaning of 
this act; and any person or persons, firm or corporation who shall manu- 
facture for sale, expose for sale, have in his or their possession for sale or 
sell any article of food or drug which is adulterated or misbranded within 
the meaning of this act, shall be fined not less than ten dollars nor more 
than one hundred dollars, or be imprisoned not to exceed fifty days or both 
such fine and imprisonment. Provided, that no article of food or drug shall 
be deemed misbranded or adulterated within the provisions of this act when 
intended for shipment to any other State or country, when such article is 
not adulterated or misbranded in conflict with the laws of the United 
States; but if said article shall be in fact sold or offered for sale for 
domestic use or consumption within this State, then this provision shall not 
exempt said article from the operations of any of the other provisions of 
this act. 

Sectio^t 2. That the term food, as used in this act, shall include every 
article used for or entering into the composition of food or drink for men or 
domestic animals, including all liquors. 

Section 3. For the purpose of this act, an article of food shall be 
deemed misbranded: 

First. If the package or label shall bear any statement purporting to 
name any ingredient or substance as not being contained in such article, 
which statement shall not be true in any part; or any statement pur- 
porting to name the substance of which such article is made, which state- 
ment shall not give fully the name or names of all substances contained in 
any measurable quantity. 

Second. If it is labeled or branded in imitation of or sold under the 
name of another article, or is an imitation either in package or label of 
another substance of a previously established name; or if it be labeled or 
branded so as to deceive or mislead the purchaser or consumer with respect 
to where the article Avas made or as to its true nature and substance or 
as to any identifying term whatsoever wherebj^ the purchaser or consumer 
might suppose the article to possess any property or degree of purity or 
qTiality which the article does not possess. 

Third. If in the case of certified milk, it be sold as or labeled "certified 
milk," and it has not been so certified under the rules and regulations by 
any county medical society, or if when so certified, it is not up to that 
degree of purity and quality necessary for infant feeding. 

In a local Louisville court, conviction and fine was obtained 
in 1908 of a dairyman, nnder the State Pure Food Laws, who 
had sold milk labeled ''Certified Milk," which had not been 
certified to by the Jefferson County Milk Commission, the pros- 
ecution being because of misbranding and a tendency to deceive 
the public. 



104 



THE DIS'EASES OF CHILDREN. 



Certified Milk is clean, cold milk which has been produced in 
a scientific manner, under rules laid down by a Medical Milk 
Commission, from a tuberculin tested, healthy herd, in properly 
constructed, clean barns, by clean, healthy milkers, in sterile 
vessels, cooled, and bottled immediately in sterilized bottles, iced 



-TO OPEN - 

PRE55 DOWN WIRE 
WITH SPOON HANDLE 





To OPE^* 



^^ 



Fig. 30. — Certified milk bottle. ^Stand- 
ard cap, protecting mouth of bottle. 



Fig. 31. — Certified milk in specie 
glasses for lunch counter trade. 



and kept cold until delivered. Milk cannot be produced in this 
manner and sell for the same price as market milk, produced 
in dirty surroundings and delivered to a city distributor in ten- 
gallon cans and then bottled or peddled from these cans from 
open measures. The bacterial content of Certified Milk can 
easily be kept below the limit of 10,000 per cc. while market 
milk is rarely found with a count of less than 100,000 per cc.^ 
Excretion of Foreign Matter in Milk. — Inflammatory condi- 
tions of the udder may result in contamination of the milk by 
the presence of pus and microorganisms from the affected parts. 
Certain foods may cause a decided odor as well as taste to cow's 



1 The Methods and Standards for the Production and Distribution of "Cer- 
tified Milk" were adopted by the American Milk Commissions, at the meeting over 
which the author had the honor of presiding, held in Louisville, May 1st, 1912. 
So important are these rules they are reproduced in full in the Appendix. 



INFANT FEEDING. 105 

milk, as when they are fed on garlic or lupines, the latter im- 
parting: a bitter taste to the milk. 

Changes in Milk Produced by Bacteria and Other Micro- 
organisms. — The commoner and well-known changes which oc- 
cur in milk as the result of the action of bacteria and other 
microorganisms are as follows : The souring of milk, with curd- 
ling, due to action of the lactic acid bacteria ; the putrefaction of 
milk, with production of various odors; the coloring of milk; 
the production of ropy milk. 

The fermentation caused by the lactic acid bacteria in milk, 
kept at ordinary temperature, is well known. The result of this 
fermentation is souring and curdling of the milk, and all other 
bacterial changes are temporarily stopped. As a result of the 
infection of the milk by other organisms, abnormal fermenta- 
tions take place, causing changes in the color, odor and taste 
of the milk. A blue discoloration of the milk is due to its con- 
tamination by bacteria, known as the Bacillus Cyanogeiies, and 
they exert their peculiar effect only after the milk has become 
sour. Others describe a red milk, but this can usually be traced 
to a cow with diseased or injured udders. Slimy or ropy milk is 
due to the organism known as B. lactis viscosus, and is found 
in the water supply of the place. 

The first few drops of milk from a healthy udder may con- 
tain a few bacteria, but the rest of the milk direct from the 
udder should be sterile. Milk is one of the best culture mediums 
and it may readily become contaminated from the air, the cow 's 
skin, hair and udder, the milker's hands or clothes, or the uten- 
sils with which the milk comes in contact. A clean, cold milk, 
from a healthy herd, will remain safe until consumed if handled 
properly. The chief aim being to keep dirt out of the milk, and 
as much comes from the cow's skin and tail, the buckets which 
have a small opening at the top and more at the side than in the 
middle, allow the milk to be drawn into it easily and prevent the 
dirt and hair dropping into it. 

If milk properly produced and handled has been cooled di- 
rectly after milking to 45° F., and kept at this temperature, the 
bacteria per cubic centimeter (20 drops) should not exceed 
10,000, while ordinary market milk will contain from 500,000 



106 



THE DISEASES OF CHILDREN. 



to several million per cubic centimeter. Clean milk, cooled and 
kept cold, will not have a great increase in bacterial content at 
the end of several days, and it can be fonnd sweet at the end of 





Fig. 32. — Gurler milk pail. Gauze fits 
over opening with layer of cotton 
between. 



Fig. 33. — Hooded milk pail. 




Fig. 34. — Certified milk shipping cases. Standard cap and seal on bottles. 

a number of days. I have drank such milk kept in this way 
when 21 days old, and milk sent to the Paris Exposition in 1900 
from Illinois, New Jersey and New York, was sweet at the end of 
14 days. This milk had been kept cold, and was clean at the 
first milking. In the Summer of 1910 on a trip to Europe we 
used Certified Milk from Louisville and drank the last quart 
which was perfectly sweet sixteen days after milking. 



INFANT FEEDING. 



107 




Fig. 34a. — Felt-lined box with removable zinc container, used in Kentucky milk 
inspection work, for collecting samples of original bottles. Larger boxes, made 
on the same style, are used for shipping. This box is so constructed as to 
maintain a temperature of from 1 to 2° C, for 24 hours. 



A^H 






.ii:-*'/^:-.-.^: 


r ji 

r 


1 ' ■BiBHI!^ 






^jiBBBh 


SPfc- 




/Mmkm. 


'^^' A 




/Mm 


WmM 










''fWjK^m 







Fig. 34b. — Box used in collecting samples of bulk milk, w'ater, and samples of milk 
from the various processes in the dairy and milk depot. Made of wood and 
felt lining and an inside copper tank. The copper tank contains a wire basket 
in several partitions, for holding 20 ordinary test-tubes. On either side of the 
basket is a copper lid, and the ice is put under the copper lid. The ends of 
the tubes extend into the iced water. The wrapped, sterile pipettes are shown, 
and as each pipette is used, it is put on the opposite side of the box. The 
copper tank can be removed and sterilized. 



NOTK — Boxes described in Figs. 34a and 34b designed and used in the milk 
inspection work of the Food and Drug Department, Kentucky Agricultural Experi- 
ment Station. Photograph furnished by R. M. xVllen, Head of Dei)artment. 



108 THE DISEASES OF CHILDREN. 

The number of bacteria in milk free from preservatives is 
a direct indication of the cleanliness employed at the dairy in 
the production of the milk, the temperature at which it has been 
kept and its age. 

Standards of bacterial contents are being adopted in many 
of the large cities. Certified milk has a limiting standard of 
10,000 per cc. ; inspected milk 100,000 per cc. (50,000 per cc. 
in Louisville), and several cities for market milk 500,000. Hence 
the bacterial count of milk is a most important procedure. 

Market Milk. — Cow's milk, to be fit for consumption by 
infants and children should answer the following requirements : 
It should be clean; from a healthy herd which has been tuber- 
culin tested; cooled immediately after milking; bottled at once 
and sealed ; contain no preservatives ; be of standard and definite 
chemical analysis and kept cold until delivered to the consumer. 

Ordinary city market milk is not fit for infant feeding. It is 
shipped to the city in large cans, hauled through the streets in 
an uncovered wagon, to the central distributing station, there 
bottled (usually in unclean bottles) and distributed, no ice being 
ever near it. Some bottle the milk in delivery wagons 'from 
large cans, the bottles being dusty and unsterilized. This milk 
contains many million bacteria, and rapidly sours in warm 
weather, even if kept on ice. 

Milk from cows kept on distillery waste or slop, or brewers' 
grain or ensilage in any state of putrefaction or fermentation, 
is unfit for consumption. Cows so fed suffer from a diarrhea, 
and the stables housing them are filthy beyond description. 
Milk produced in such barns contains myriads of bacteria. 

Tuberculosis. — Since Koch advanced his dictum in 1901 that 
bovine tuberculosis was not transmissible to man, scientists of 
the world have been at work to disprove it. This has unques- 
tionably been done. Undoubted cases of direct transmission 
have been recorded by Jensen, ^ a few of which may be men- 
tioned : 

1. The 17-year-old daughter of Prof. Gosse died of abdominal tuber- 
culosis after drinking milk from cows affected Avith udder tuberculosis. 
Other sources of infection could not be discovered. 



1 Jensen's Milk Hygiene. 



INFANT FEEDING. 109 

2. Oliver's observation concerns one of the best-proved cases of trans- 
mission by milk. In a boarding school 12 young girls became ill with 
signs of intestinal tuberculosis and five of them died. All came from 
healthy families and no source of infection was found but one cow which 
supplied milk for the school, and was shown to be affected with tuber- 
culosis of the udder. 

3. Demme has reported the following: In the children's hospital, Bern, 
four children died of intestinal and mesenteric glandular tuberculosis. He 
was able to exclude all other sources of infection and to prove that the 
milk came from tuberculous cows. 

4. Hills tells of a 21-months-old child that was affected with intestinal 
tuberculosis three months after making an eight-day visit to an uncle 
where it had drank the milk of a cow having advanced tuberculosis. The 
child died of tuberculosis. Other sources of infection were excluded and 
another child fed only with sterilized milk remained healthy. 

5. Ernst reports that three children of the same family died of tuber- 
culosis after drinking milk from a cow that died of general tuberculosis 
with udder involvement. 

MoMer ^ states that : 

The finding of the bovine type of tubercle bacillus in human 
lesions is the most direct and positive proof that tuberculosis 
of cattle is responsible for a certain amount of tuberculosis in 
the human family. Numerous experiments with this object in 
view have already proven this fact. Thus the German Commis- 
sion on Tuberculosis examined 56 different cultures of tubercle 
bacilli of human origin and found six Avhich were more virulent 
than is usual for human tubercle bacilli, causing marked lesions 
of tuberculosis in the cattle inoculated with them, and making 
over 10 per cent of the cases tested that were affected with a 
form of tuberculosis which, by Koch's own method, must be 
classified as of bovine origin. The bacilli, with the exception 
of a single group, were all derived from the bodies of children 
under seven years of age, being taken from tubercular ulcers 
in the intestines, the mesenteric glands or from the lungs. 

In a similar series of tests conducted by the British Royal 
Commission on Tuberculosis, 60 cases of the disease in the human 
were tested, with the result that 11 cases were claimed by this 
connnission to have been infected from bovine sources. Ravenel 
reports that of five cases of tuberculosis in children two received 



1 Bulletin 14, Hygienic Laboratory, 



110 



THE DISEASES OF CHILDREN-. 



their infection from cattle. Theobald Smith has also reported 
on one culture of the bovine tubercle bacillus obtained from 
the mesenteric glands of a child out of five cases examined, and, 
according to a recent paper by Goodale, Smith has recently been 
at work on seven other cultures from different children, four 
of which conformed to his idea of tubercle bacilli emanating 
from cattle. Of four cases of generalized tuberculosis in chil- 
dren examined in the Biochemic Division of the Bureau of 
Animal Industry, two were found to be affected with very viru- 




Fig. 35. — A sample of the unsuspected but dangerous tubercular cow. Rejected by 
the veterinarian after test. 

lent organisms, which warranted the conclusion that such chil- 
dren had been infected from a bovine source. The Pathological 
Division of the same Bureau has likewise, out of the nine cases 
of infantile tuberculosis examined, obtained two cultures of 
tubercle bacilli that could not be differentiated from bovine 
cultures. In Europe so many similar instances of bovine tuber- 
cle bacilli having been recovered from human tissues are on 
record that it appears entirely proven that man is susceptible 
to tuberculosis caused by animal infections, and while the pro- 
portion of such cases cannot be decided with even approximate 
accuracy, it is nevertheless incumbent upon us to recommend 
such measures as will guard against these sources of danger 
when enforced. 



INFANT FEEDING. Ill 

Tuberculosis is markedly prevalent throughout the United 
States in dairy cattle. It is estimated that in certain sections 
it affects from 20 to 60 per cent of the members of all herds. 
In Washington 16.9 per cent of 1538 cattle tested reacted to the 
test. It is conceded by all that local tuberculosis in the udder 
will result in contamination of the milk with tubercle bacilli, 
and that in other forms of bovine tuberculosis, as of the intestine 
and lungs, great quantities of bacilli are excreted by the dis- 
charges which may contaminate the milk. It has been found, 
for instance, that 70 per cent of all milk examined in Washing- 
ton, D. C, contained dirt, and microscopic examination showed 
it to be fecal in character, hence the frequency of contamination 
by tubercle bacilli. 

Tuberculin Test. — The tuberculin used in this test is the ster- 
ilized and filtered glycerine extract of cultures of tubercle bacilli. 
In the hands of competent men it is practically an infallible 
test, and a cow which reacts to the test should be slaughtered at 
once. This should be under State indemnification, for without 
State aid the disease will not be eradicated. 

If the injected animal is normal the result of the tuberculin 
injection will be negative, that is, she will not show a rise in 
temperature. 

The "test" is applied as follows: The temperature of the cow 
is taken in the rectum at two-hour intervals for 12 hours and the 
variations noted. That night about 9 p. m. the tuberculin is 
injected hypodermatically in a shaved portion of the skin of the 
hip. The following day the temperatures are taken again and 
recorded, as nearly as possible every two hours, and continued 
for 20 hours. 

In the markedly tubercular a small dose of the tuberculin 
may show no reaction. A tolerance is shown for the tuberculin 
for six weeks after an injection. 

A reaction may be found in advanced pregnancy, during the 
oestrum and in concurrent diseases, as inflammations of the lungs, 
intestines or uterus ; or when a sudden change is made in the 
feeding during Jthe test. 

In reading the temperatures taken after the test, a rise of 2° 
F. is not noted. It should ffo above 103.8° F. Cows reacting 



112 THE DISEASES OF CHILDREN. 

should be slaughtered at once and examined by veterinary ex- 
perts capable of detecting minute as well as gross lesions. 
Salmon concludes as follows, regarding the tuberculin test: 

1. That the tuberculin test is a wonderfully accurate method 
of determining whether an animal is affected with tuberculosis. 

2. That by the use of tuberculin the animals diseased with 
tuberculosis may be detected and removed from the herd, thereby 
eradicating the disease. 

3. That tuberculin has no injurious effect upon healthy 
cattle. 

4. That the comparatively small number of cattle which have 
aborted, suffered in health or fallen off in condition after the 
tuberculin test, were either diseased before the test was made 
or were affected by some cause other than the tuberculin. 

A cow may be dangerously tubercular as shown by Schroeder ^ 
long before she shows clinical evidences of tuberculosis. She 
may not cough, may eat well, calve, and in every way appear nor- 
mal, yet be excreting millions of bacilli before the presence of 
tuberculosis is determined by the tuberculin test. 

Epidemics Due to Milk. — Specific organisms may contaminate 
milk and cause epidemics among its users. Typhoid fever is 
more frequently spread through the medium of water, next by 
milk. Jensen records 90 epidemics of typhoid in Copenhagen, 
from 1878 to 1896. I have traced one in Louisville where there 
were 54 cases in a small territory, 44 of whom used milk from 
one dairy. In one family only one person used unboiled milk 
and she contracted typhoid. Typhoid bacilli were demonstrated 
by the late Dr. Louis Vissman in the water used on this dairy- 
man's place for can washing. Diphtheria may be milk borne, 
also. Smithbank and Newman ^ record 100 cases in Ashtabula, 
Ohio, affected with diphtheria in 1894. Milk was delivered to 
all by the same dairyman. A farm hand had a sore throat, and 
he had assisted at the work of the dairy while so suffering. 

Scarlet fever epidemics have undoubtedly been traced to milk. 
Touching this point of epidemics due to milk, Busey and Kober 
gave a summary of the epidemics compiled by them as follows : ^ 



1 Bulletin 114, U. S. B. A. I. 

^ Jensen. 

3 Hygienic Laboratoi'y Bulletin 14, Marine Hospital Service. 



INFANT FEEDING. • 113 



TYPHOID FEVER EPIDEMICS. 

Mr. E. Hart tabulated 50 epidemics of typhoid fever and we have col- 
lected 88, making a total of 138 epidemics traceable to a specific pollution 
of the milk, the main facts of which are presented in a subjoined table. 
In 109 instances there is evidence of the disease having prevailed at the 
farm or dairy. In 54 epidemics the poison reached the milk by soakage of 
the germs into the well water with which the utensils were washed and 
in 13 of these instances the intentional dilution with polluted water is 
admitted. In 6 instances the infection is attributed to the cows drinking 
or wading in sewage-polluted water. In three instances the infection was 
spread in ice cream prepared in infected premises. In 21 instances the 
dairy employees also acted as nurses. In 6 instances the patients while 
suffering from a mild attack of enteric fever, or during the first week or 
ten days of their illness continued at work and those of us who are familiar 
with the personal habits of the average dairy boy will have no difficulty 
in surmising the manner of direct digital infection. In one instance the 
milk tins were washed with the same dishcloth used among the fever 
patients. In one instance the disease was attributed to an abscess of the 
udder, in another to a teat eruption, and in one to a febrile disorder in the 
cows. Four were creamery cases. In one the milk had been kept in the 
sick room. 

SCARLET FEVER EPIDEMICS. 

Mr. Hart collected 15 epidemics of milk scarlatina, and we have tabulated 
59, making a total of 74 epidemics spread through the medium of the milk 
supply, the details of which will be found in Table No. II. 

In 41 instances the disease prevailed either at the milk farm or dairy. 
In 6 instances persons connected with the dairy either lodged in or had 
visited infected houses. In one the milkman had taken his can into an 
infected house. In 20 instances the infection was attributed to disease 
among the milch cows; in 4 of these the puerperal condition of the animal 
is blamed. In 9 instances disease of the udder or teats was found. In one 
instance the veterinarian diagnosed a case of bovine tuberculosis. In 6 
instances there was loss of hair and casting of the skin by the animal. In 
No. 68 the cattle were found to be suffering more or less from febrile dis- 
turbance. In 10 instances the infection was doubtless conveyed by persons 
connected with the milk business, while suffering or recovering from an 
attack of the disease and in at least 8 cases by persons who also acted as 
nurses. In three instances the milk had been kept in the cottage close 
to the sick room. In one the cows were milked into an open tin can which 
was carried across an open yard past an infected house, and in one the 
milkman had wiped his cans with white ffannel cloths (presumably infected) 
which had been left in his barn by a peddler. Two appear to have been 
instances of mixed infection of scarlet fever and diphtheria. 



114 THE DISEASES OF CHILDREN. 

DIPHTHEKIA EPIDEMICS. 

Mr. Hart collected 7 epidemics of milk diphtheria and we have added 21 
more. In 10 of these 28 instances diphtheria existed at the farm or dairy, 
and in 10 instances the disease is attributed directly to the cows having 
garget, chapped and ulcerative affections of the teats and udder, while 
in one the cows were apparently healthy but the calves had diarrhea. In 
one case one of the dairymaids suffered from a sore throat of an erysipe- 
latous character, and in one the patient continued to milk while suffering 
from diphtheria. In one, one of the drivers of the dairy wagons was suf- 
fering from a sore throat. 

Care of Milk in the Home. — But little care is taken of milk 
in the home of the consumer. Many homes do not have ice either 
in winter or summer and it is entirely impossible to keep milk 
sweet in summer without ice. 

The average time for delivery of milk in the city is from 4.30 
a. m. to 6 a. m. It is left upon the door step or shelf by the 
kitchen door, frequently in summer in the sun, from the time 
it rises until the servants arrive, when the bottles may or may 
not be put on ice at once. Among the poorer classes the milk- 
man rings a bell from his wagon and the customer comes out 
with an open bucket and the milk is drawn from a can which 
has been hauled around the city, in the sun, and without a pro- 
tecting cover, this milk having never been aerated or cooled. 

Milk should not be kept in uncovered vessels or in a refriger- 
ator with vegetables, especially those which give off an odor. 

Among the well- to-do the use of a thermal bottle, an appliance 
for keeping hot things hot and cold things cold, has been sug- 
gested as a labor saver to keep the baby's milk warm -at night. 
By keeping milk warm for several hours at a temperature of 
95° F. to 100° F., bacterial growth is very rapid and the milk 
entirely unfit for use. The sale of these bottles for such purposes 
should be prohibited by law. 

Recently a breast-fed baby seven months old, under my ob- 
servation, had been stationary in weight for several weeks, 
and the last week had lost in weight. It was decided to sup- 
plement the breast feeding by two bottles of modified milk a 
day. This was done, with a slight gain in weight but a 
report of thin green stools. Inquiry developed the fact that 



INFANT FEEDING. 115 

one feeding at night and the first morning feeding were pre- 
pared and kept warm in a "thermos" bottle. I had some milk 
prepared as usual the next night and the bottle was not opened 
until the following morning, when some of it was plated, and as 
a control, some of the Certified milk delivered the same day 
and from which the sample in the ''thermos" was prepared, also 
plated. 

The Certified milk showed a count) of 3400 bacteria per 
cc, and the milk in the thermos bottle 1,400,000. The child 
improved at once upon discontinuing the use of the thermos 
bottle. 

MORBIDITY AND MORTALITY STATISTICS AS 
INFLUENCED BY MILK.i 

It has been estimated that 23 gallons of milk are purchased 
for each person in the United States each year. This very great 
consumption of one commodity must, have some influence on the 
population, for good or bad. As children under one year of 
age are the chief users of milk, it must be to statistics we must 
look for an answer to the question : Does milk have any influ- 
ence upon mortality statistics? 

The United States Census Office reports a population of 
33,757,811. There were 545,533 deaths of all ages and 105,553 
deaths in infants under one year of age. 

Diarrhea and enteritis caused the death of 39,399 infants 
in their first year of life. These figures show a large proportion 
of the total deaths are in infants under one year of age, and 
a large proportion of these deaths are due to digestive disorders. 
Eager points out that a child consumes 500 quarts of milk 
during its first year, and practically to the exclusion of other 
articles of diet, hence it is safe to conclude that milk is the 
cause of the digestive disturbances which result fatally. It 
is shown also that the mortality in artificially-fed children is 
far greater than in children nursed at the breast. Newsholme - 
states that, taking the whole first year of life, the number of 



1 Eager: Bulletin 14, Hygienic Laboratory. 2 Loc. fit. 



116 



THE DISEASES OP CHILDREN. 



deaths from epidemic diarrhea among breast-fed babies is not 
more than one-tenth the number among artificially-fed infants. 

Epidemics and tuberculosis from a milk source have already 
been referred to. It can readily be inferred that an exhaustive 
study of the milk question as it relates to infant mortality is 
amply justified. 

Sterilization and Pasteurization. — Milk brought to the tem- 
perature of 212° F. for 15 minutes is sterilized; when brought 
to 167° F. to 170° F. for 20 minutes it is Pasteurized, the dif- 





Fig. 36. — Castle Pasteurizer. 



Pig. 37. — Hygeia Pasteurizer. 



ference being entirely the amount of the heat used. Sohxlet, 
in 1886, advised the heating of milk for infant feeding and 
described an apparatus for carrying this out in the home. 

When it is impossible to obtain a milk for infant feeding 
which is known to be clean and cold, or the milk contains a 
quantity of sediment, and sours easily, it is decidedly best to 
submit it before feeding to sterilization or Pasteurization. Pas- 
teurized milk means "heated milk," and does not necessarily 
mean ''clean, good or pure milk." 

Both of these processes destroy bacteria, but do not entirely 
destroy the spores. After heating, unless the milk is kept be- 
low 50° F. these spores germinate, and a new strain of bacteria 
are produced which multiply rapidly. The germs most fre- 
quently found in milk are the tubercle bacillus, typhoid bacillus, 
Klebs-Loeffler bacillus, the pyogenic cocci and the virus of foot 



INFANT FEEDING. 117 

and mouth disease of cattle. These are all killed at even a 
lower temperature than 107° F., if maintained long enough. 

The chief difficulty in wholesale Pasteurization of milk is its 
being heated in bulk and put in unsterilized containers, either 
bottles or cans. To be entirely effective it should be first bot- 
tled, under as strictly cleanly auspices as possible, then Pasteur- 
ized, cooled immediately, and kept cold until consumed. Unfor- 
tunately the Pasteurization or sterilization of milk lulls one 
into a false feeling of security in regard to it. The general 
belief is that the milk so treated will keep indefinitely and 
without ice, whereas if such a sample of Pasteurized milk is 
plated it will be found to contain many thousand bacteria. It 
has been suggested by the New York City Milk Committee's 
report to the Mayor, that when Pasteurized milk is found to 
contain 50,000 bacteria to the cubic centimeter it should be 
destroyed. 

The result of a number of counts made of a commercially- 
Pasteurized milk in Louisville showed an average of 200,000 
bacteria per cubic centimeter. 

Effect of Heat. — Owing to the lactic acid bacteria being de- 
stroyed by heat, milk so treated does not sour, but slowly putre- 
fies. The growth of the putrefying bacteria in raw milk is in- 
hibited by the lactic acid bacteria. The effect of heat upon milk 
depends upon the degree of heat. It to some extent coagulates 
the albumin and renders the milk less coagulable by rennet. The 
exact change which takes place in milk after heating is not 
known, and there is not sufficient clinical data at hand to posi- 
tively prove that heated milk is insufficient for the nutritional 
needs of the child. Milk of Certified grade is best for an infant. 
Market milk unless it has been Pasteurized is unfit for artificial 
feeding and Pasteurization is preferable to sterilization. 

Composition of Milk. — The milk from cows of different 
breeds contains the same ingredients, but in different propor- 
tions, as shown by the following table, the results of quantita- 
tive analysis. 1 These proportions vary according to the breed 
of the cow, condition of the cow and the time and method of 
milking. 

1 Winslow from Gordon's Tables. 



118 



THE DISEASES OP CHILDREN. 



Fat 

Sugar 

Proteid 

Mineral matter 



DURHAM 












OR 
SHORT- 


DEVON 


AYR- 
SHIRE 


HOLSTEIN 
FRESIAN 


JERSEY 


Bpovvn 

SWISS 


HORN 












4.04 


4.09 


3.89 


3.2 


5.22 


4.0 


4.34 


4.32 


4.41 


4.33 


4.84 


4.30 


4.17 


4.04 


4.01 


3.90 


3.58 


4.00 


0.73 


0.73 


0.73 


0.74 


0.73 


0.76 



COM ON 
NATIVE 



3.69 
4.35 
4.09 
0.76 



Leach ^ gives the following analyses showing the composition 
of milk of the human and a number of different animals: 



800 



200 



200 



32 



KIND 
OF MILK 



Cow's milk. 
Minimum . . 
Maximum . . 

Mean 

Human milk 
Minimum . . 
Maximum . . 

Mean 

Goat's milk: 
Minimum . . 
Maximum . . 

Mean 

Ewe's milk: 
Minimum . . . 
Maximum . . . 

Mean 

Mare's milk: 

Mean 

Ass's milk: 
Mean 



SPECIFIC 
GRAVITY 


WATER 


CASEIN 


AIBU- 
MIN 


TOTAL 
PhO- 
TUDS 


FAT 

1.67 


MILK 
SUGAR 


1.0264 


80.32 


1.79 


0.25 


2.07 


2.11 


1.0370 


90.32 


6.29 


1.44 


6.40 


6.47 


6.12 


1.0315 


87.27 


3.02 


0.53 


3.55 


3.64 


4.88 


1.027 


81.09 


0.18 


0.32 


0.69 


1.43 


3.88 


1.032 


91.40 


1.96 


2.36 


4.70 


6.83 


8.34 


— 


87.41 


1.03 


1.26 


2.29 


3.78 


6.21 


1.0280 


82.02 


2.44 


0.78 





3.10 


3.26 


1.0360 


90.16 


3.94 


2.01 


— 


7.55 


5.77 


1.0305 


85.71 


3.20 


1.09 


4.29 


4.78 


4.46 


1.0298 


74.47 


3.59 


0.83 





2.81 


2.76 


1.0385 


87.02 


5.69 


1.77 


— 


9.80 


7.95 


1.0341 


80.82 


4.97 


1.55 


6.52 


6.86 


4.91 


1.0347 


90.78 


1.24 


0.75 


1.99 


1.21 


5.67 


1.036 


89.64 


0.67 


1.55 


2.22 


1.64 


5.99 



0.35 
1.21 
0.71 

0.12 
1.90 
0.31 

0.39 
1.06 
0.76 

0.13 
1.72 
0.80 

0.35 

0.51 



On the proteid the body must depend for its growth and 
development, furnishing the material for repair of waste going 
on in the tissues as well as for its growth. 

Allen - has suggested the term proteid quotient to represent 



1 Hygienic Laboratory Bulletin No. 41. Marine Hospital Service. 

2 Journal American Medical Association, November 14, 1908. 



INFANT FEEDING, 119 

the amount of proteid in quantity per pound per day needed 
by the child for its nourishment. He estimates this as 0.04 to 
0.045 of an ounce for each pound of the baby's weight, and 
gives the following- working figures: If the milk contains 3.5 
to 4 per cent of proteid, it will be necessary to give 1 to 1.5 
ounces of milk to the pound. 

Proteids. — Van Slyke ^ and others have made investigations 
of the chemistry of milk which have been of great value. 

Our knowledge regarding the nitrogen compounds of milk 
has been very indefinite, especially with reference to their 
nomenclature. Some have named as many as seven compounds, 
but those most freciuently described are casein (caseinogen or 
milk casein), lactalbumin and lactoglobulin. 

The most important of these is the milk casein which is found 
in combination as calcium casein, and is that portion of milk 
which coagulates in sour milk or as the result of acid or rennet 
precipitation. 

All the elements necessary for nutrition are present in casein, 
namely, carbon, hydrogen, nitrogen, sulphur and phosphorus. 

Van Slyke and Hart - have studied the action of acids, alka- 
lies, heat and rennet on calcium casein. They found that with 
dilute acid there is a combination of the acid and the calcium, 
and the casein is set free. On the addition of further acid the 
casein molecule combined directly with the acid, forming a 
salt of the acid. The casein and the casein salts of acids are 
insoluble, the coagulum being casein lactate. The casein and 
casein salts dissolve in excess of acid. 

Dilute alkaline solutions, such as the carbonates of sodium, 
potassium and ammonium react with free casein or its salts with 
acids, and form compounds that are easily soluble in water. 

Heat alone at the boiling point of water does not coagulate 
casein in milk. The skin which forms on milk heated above 
140° F. is due to the calcium casein. 

The most characteristic action of any is that of rennet on 
milk. Calcium paracasein is coagulated, the change being a 
physical one only. To obtain prompt action of rennet the milk 



1 Archives of Pediatrics, July, 1905. 

2 Archives of Pediatrics, July, 1905. 



120 THE DISEx\SES OF CHILDREN. 

must not be alkaline ; it must not be diluted with water ; must 
not be heated over 106° or 108° F. The rennet and the milk must 
be fresh, and the milk should not be boiled. 

In case of milk containing 3.00 to 4.50 per cent of fat, 
Van Slyke ^ has suggested the following formula for calculating 
the amount of casein: 

{F-3) X 0.4 X 2.1 = per cent of casein in the milk. 

F. in the equation, equals the number representing the percentage of fat 
in the milk. 

Lactalbumin is not acted on by rennet, is not coagulated by 
acids at ordinary temperature, and is coagulated by heat above 
160° F. The ratio of calcium casein to lactalbumin is given 
as 3.6 to 1. 

Ladoglotulin is present in very small quantities in milk. 

Van Slyke gives the following figures to serve as a guide to 
approximately figure the amount of casein and albumin in milk, 
the fat content being known: 

Per cent of fat in 
norm.al milk 

3.0 

3.5 

4.0 

4.5 

5.0 

5.5 

6.0 

Carbohydrates occur in milk in the form of milk sugar or 
lactose (Ci2 H22 0^ HoO). The souring of milk occurs as the 
result of the action upon the lactose by the lactic acid bacteria. 
If the milk is kept cold these bacteria will not propagate readily. 

The fat content of milk is found in homogeneous emulsion, 
composed of small droplets or globules fairly similar in size. 
The chief fats contained in the fat mixture of milk are olein, 
palmitin and stearin. The fat readily separates from the 
remainder of the milk, forming, on standing, a distinct deeper- 
colored layer above. The fat can be artificially separated by 
means of a centrifugal machine called the '' separator." It has 
been claimed by some authorities that separated cream could 



Per 


■ rent of c^'sein 
and albumin 




2 


.90 




3 


.10 




3 


.30 




3 


.50 




3 


.65 




3 


.80 




3 


.95 



1 New York Medical Journal, May 30, 1908. 



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121 



122 



THE DISEASES OF CHILDREN. 



not be reunited with the fat-free milk in the homogeneous mix- 
tures as before separation, but this has not been entirely proven. 

The inorganic salts contained in the milk in solution consist 
chiefly of lime, potash, sodium. These can be separated by 
incineration, and are referred to as the ash. 

The tables of Van Slyke and Babcock on preceding page 
show the quantities of these substances just enumerated, in cow 's 
milk. 

Score Cards. — The Bureau of Animal ludustry, Department 
of Agriculture of the Government, has suggested a method of 
scoring dairies, herds and milk, and samples of these are here 
reproduced : 

(United States Department of Agriculture, Bureau of Animal Industry, 

Dairy Division) 
Sanitary Inspection of Dairies 

Owner or lessee of farm 

Town State 

Total No. of cows No. milking Quarts of milk produced 

daily 

Is product sold at wholesale or retail ? 

If shipped to dealer give name and address 

Permit No Date of inspection 190 . . 



Cows. 

Condition (2) 

Health (8) 

Cleanliness 

Water supply 

S tables. 

Construction 

Cleanliness 

Light 

Ventilation (4) 

Cubic space per cow (3) . . 

Removal of manure (2) . . 

Stable yard ( 1 ) 

Milk House. 

Construction (2) 

Equipment (3) .' 

Cleanliness 

Care and cleanliness of 
utensils 

Water supply (Temp. °F.) 



SCORE 



Perfect Allowed 



10 

5 
5-20 

5 
5 
5 

7 
3-25 

5 
5 

5 
5-20 



REMARKS 



INFANT FEEDING. 



I2:r; 





SCORE 


REMARKS 




Perfect 


Allowed 


Milkers and Milking. 

Health of attendants 

Cleanliness of milking... 
Handling the Milk. 

Prompt and efficient cool- 
ino" 


5 

10-15 

5 

100 


















(Temperature of milk °F) 
Storing at a low tempera- 
ture 














Protection during trans- 






















Sanitary conditions are : Excellent 

Suo'gestions by inspector 


Glood 


. Fair Poor 


Signed 








INSPECTOR. 



Sanitary inspection of dairies (reverse side). 
Handling the Milk. 

Prompt and effieient cooling: If prompt (a), 5; efficient (b). if 50° 
F. or under, 5; over 50° and not over 55°, 4; over 55° and not over 
60°, 3; over 60°, 0; if neither prompt nor efficient, 

Storing at low temperature: If 50° F. or under, 5; over 50° and not 
over 55°, 4; over 55° and not over 60°, 3; over 60°, 

Protection during transportation to market: If thoroughly protected 
(iced), 5; good protection, 4; partly protected, 2; otherwise, 0. . . . 



10 



SCORE. 

If total score is 90 or above and each division 85 per cent perfect or over, 
the dairy is Excellent (entitled to registry). 

If total score is 80 or above and each division 75 per cent perfect or 
over, the dairy is Good. 

If total score is 70 or above and each division 65 per cent perfect or over, 
the dairy is Fair. 

If total score is below 70 and any division is below 65 per cent perfect, 
the dairy is Poor. 

Note. On the reverse side are directions for scoring cows, stables, milk 
house and milking. 

Care of Bottles and Nipples. — Definite and positive directions 
must be given the mother, and to the nurse, in the mother's 
presence, as to the care of the bottles and nipples, and a bottle 



124 THE DISEASES OF CHILDREN. 

should be selected which is most easy to clean. The Hygeia 
nursing bottle has a wide mouth and a large nipple, both of 
which are very easily cleaned and sterilized. The Arnold 
Pasteurizing bottle is difficult to clean because of the narrow 
opening, it being necessary to use a brush in washing. The 
same objection obtains in the Whitehall-Tatum bottle, which has 
a wide, flaring base. 

New bottles can be annealed by placing them in a vessel of 
cold water, bringing it to a boil, allowing the bottles to remain 
in the water till cold. They crack less readily when so treated. 

If more milk has been prepared than the baby will take at 
a nursing, when the child has finished, the bottle should at once 
be emptied, rinsed with cold water, then with hot, and filled 
with soda solution, which is allowed to remain in it until the 
milk is prepared the following day for the next 24 hours. The 
bottles are then partly filled with soap and water, a tablespoon- 
ful of bird gravel is poured in and the bottles each thoroughly 
shaken, this doing away with the necessity for a brush. They 
are then rinsed and boiled when they are then ready for use. 
They should be kept standing bottom up until filled with the 
modified milk. 

Enough nipples should be at hand to use a different one for 
each feeding. After a feeding they are washed, turned inside 
out and allowed to remain in a soda or boracic acid solution 
and boiled with the bottles the following day. Under no cir- 
cumstances should a long-tube nursing bottle ever be used. It 
is absolutely impossible to cleanse the tube, and it is a constant 
source of infection. 

The aperture in a nipple should only be large enough to allow 
milk to escape from it, with the bottle inverted, in drops in 
quick succession. If it drops very slowly the opening is too 
small, and should be enlarged very little by the point of a hot 
needle. If the milk runs in a fine stream the opening is too 
large and the nipple should be discarded. 

The bottle is stood in a cup of hot water until the milk is 
about 90° F. The temperature of the milk can be ascertained 
by allowing a few drops to trickle on the back of the hand or 



INFANT FEEDING. 



125 



wrist. The practice of some nurses of drawing a few drops 
from the nipple with the mouth to learn the temperature of the 
milk cannot be too strongly condemned. 

Modified Milk or Percentage System of Feeding. — Because of 
the marked difference between the amount of proteids of cow's 
milk and mother 's milk, cow 's milk must ■ be so altered as to 
change its fat, sugar and proteid content that it will, as nearly 
as possible, be adapted to the digestive capacity of the infant 
and nourish it properly. This may be done in several ways, 
first by using a definite percentage, centrifugal cream in con- 
nection with skim milk and a diluent, and the addition of 
sugar of milk in order to bring the carbohydrate up to the 
proper amount. Second, by diluting top milk, which is a speci- 
fied number of ounces from the top of a cjuart bottle of milk 
which has stood four hours in order to alloAv the cream to 
rise. Third, by dilution of whole milk. 

The ideal method of milk modification is by means of the 
milk laboratory where a physician's prescription for a definite 
amount of the various ingredients of milk can be written upon 
a blank, and this filled at the laboratory as a prescription for 
medicine is in a drug store. The best example of this is the 
Walker-Gordon laboratory, which has established branches in 
many of the largest cities of the United States. The following 
is a prescription blank which is used in connection with one 
of these laboratories : 



PER CENT 



Fat 

INIilk-Sugar . . . 
Albuminoids . . 
Mineral Matter 



Total Solids 

Water ad 







100 


00 



REMARKS 



JSTiimber of feedings 

Amount of each feeding 

Alkalinity per cent 

Heat at °F. 



Infant's age . . 
Infant's weight 



Order 
Date 



190 



Signature 



26 



THE DISEASES OF CHILDREN. 



The following is the latest modified milk prescription card sug- 
gested by Dr. Rotch: 

NEW PKESCRIPTION CARD SUGGESTED BY DR. ROTCH FOR LABORATORY USE. 



EXPLANATORY. 



fri) Gravity cream will 
be used, instead of 
centrifugal if or- 
dered. 

fh) The maximum 
amount of starch 
possible in any pre- 
scription when used 
as a nutrient is 1.30 
per cent. It re- 
quires 0.75 per cent 
starch to make the 
precipitated casein 
hner. 

t'c) One hour completely 
dextrinizes starch. 

(d) In case physicians 
do not wish to sub- 
divide the proteids, 
the words "Whey" 
and "Casein" may 
be erased. 

(e) It requires 0.20 per 
cent of the milk and 
cream used to facili- 
tate the digestion of 
the proteids, i.e., the 
formation of a soft 
curd; 0.40 per cent 
to prevent the action 
of rennet, i.e., the 
formation of a tough 
curd. 

(f) Twenty minutes ren- 
ders the mixture de- 
cidedly bitter. 



(a) Fats 



(h) Carbohydrates - 



Lactose (milk su- 
gar) 

Maltose (malt su- 
gar) 

Sucrose (cane su- 
gar) 

Dextrose (grape 
sugar ) 
[ Starch ( b ) 



(c) Dextrin ize 



(e) Sodium Citrate 



(f) Peptonize 



INFANT FEEDING. 



127 



EXPLANATORY. 



(g) It requires 20 per 
cent of the milk and 
cream used in modi- 
fying to facilitate 
the digestion of the 
proteids. 50 per 
cent of the amount 
of milk and- cream 
used suspends all ac- 
tion on the proteids 
in the stomach. 5 
per cent of the total 
mixture gives a 
mildly alkaline food. 

(h) It requires 0.68 per 
cent of the milk and 
cream used in modi- 
fying to facilitate 
the digestion of the 
proteids. 1.70 per 
€ent of the amount 
of milk and cream 
used suspends all ac- 
tion on the proteids 
in' the stomach. 0.17 
per cent of the total 
mixture gives a 
mildly alkaline food. 

(i) Percentage figures 
represent the pei 
cent of lactic acid 
attained when the 
food is removed 
from the thermostat. 
When the lactic acid 
bacillus is used to 
facilitate the diges- 
tion of the proteids, 
the percentage called 
for represents the 
final acidity, as the 
process is stopped 
by heat at this point. 



PER 
CENT. 



(g) Lime water 



Per cent of milk and 
cream 

Per cent of total mix- 
ture 



(h) Sodium Bicarb, 



Per cent of milk 
and cream .... 

Per cent of total 
mixture 



(i) Lactic Acid Bacillus 



rd) To facili- 
tate digestion 
of proteids. 
-^ (2) To inhibit 
the saprophy- 
tes of fermen- 
tation. 



128 



THE DISEASES OF CHILDREN. 



EXPLANATORY 



When the lactic acid 
bacillus is used to 
inhibit the growth 
of saprophytes, the 
acidity may subse- 
quently increase to 
a variable degree, as 
the bacilli are left 
alive. 0.25 per cent 
lactic acid just 
curdles milk, 0.50 
per cent gives thick 
curdled milk. 0.75 
per cent separates 
the milk into curds 
and whey. 



PEE 

CENT. 



When the lactic acid bacillus is not 
called for in the prescription, heat 
at. . . .°F 

Number of feedings 

Amount at each feeding oz. 



A modifying laboratory has been in operation in connection 
with the experiment station of the Kentucky Agricultural Col- 
lege of Lexington, Ky., for several years, and the distributing 
plant of certified milk in Louisville, and the Babies' Milk Fund 
Association each operate a laboratory. 

To obtain a proper conception of milk modification it is posi- 
tively necessary for one to think of a milk mixture as presenting 
a given percentage of the principal ingredients of milk, namely, 
fat, sugar and proteid, and not of how many ounces it takes 
to make a certain solution or how many times a given quantity 
of milk is to be diluted. One must think in percentages and not 
in ounces. He must remember that the basis of all prescription 
modification is the average analysis of mother's milk and cow's 
milk. 

Dr. T. M. Kotch of Boston first suggested the establishment 
of milk laboratories, and to him and the Messrs. Walker and 
Gordon are due the developments along this line. 

The home modification may be accomplished in various ways, 
some more or less complicated, all, however, having the same end 
in view, that of combining cream, milk sugar and diluent in 
such proportions that when analyzed it will show a result sim- 
ilar to an analysis of mother's milk. 

Before any prescription for modified milk is given, the milk 
to be used should be examined for the amount of fat content, 



INFANT FEEDING. 



129 



•$-9 



the proteid in practically all grades of milk being from 3.2 to 

4 per cent. 

Estimate of Fat Percentage. — In almost any community can be 
found a Babcock milk tester, a centrifugal 
apparatus for the estimation of butter fat 
in milk. In the graduated bottle of the 
tester is poured 16.5 cc. of milk, to this is 
slowly added 17.5 cc. of commercial sul- 
phuric acid (specific gravity of 1.82), the 
bottle being gently agitated as it is poured 
in. The milk is curdled, but agitation dis- 
solves the curds. Hot water is then added 
as far as the beginning of the tube end of 
the bottle. It is then placed in the machine 
and revolved, the number of revolutions to 
be employed per minute being marked on 
the cover of the tester. More water is 
added, half way of the tube, and centrifu- 
gated again for two minutes. Water is 
again added to the line indicated on the 
scale and centrifugated for two minutes. 
The fat has completely separated now and 
occupies the top of the column. This is 
read, the highest and lowest parts of the col- 
umn of fat marking the limits of the fat 
percentage. 

A very rich milk is not often found in 
cities. If an analysis is not possible, aver- 
age milk may be considered to contain from 
3.5 to 4 per cent of fat, 4 per cent of sugar 
and 4 per cent proteid. 

Top Milk. — An average milk, if allowed Pig. 38.— Babcock butter 
to stand for hours in a quart bottle on ice, 
will yield in its top 20 ounces 5.8 per cent of fat; the 
top 16 ounces 7 per cent fat; the top 9 ounces 11.5 
per cent fat; the top 6 ounces 16.8 per cent, and the top 

5 ounces 19.2 per cent fat, and by diluting these top milks 
almost any percentage of fat, proteid and sugar can be 




130 



THE DISEASES OF CHII.DKEN. 




obtained. It should be remembered, however, that the proteid 
in a 16-ounce top milk is the same as in Avhole milk, viz., 4 per 
cent. The chief thing to remember, then, is that the top 16 
ounces contain 7 per cent fat and 4 per cent proteid, and the 
top 9 ounces 11.5 to 12 per cent fat and 4 per cent proteid. 
The proteid content can be increased by adding skim milk 
or whey. The carbohydrate content is in- 
creased by the addition of sugar of milk. 
The proteid content of the milk may be 
modified by the addition of lime water or 
carbonate of potassium. Those alkaline 
agents limit the rennet action on the milk 
and smaller curds are formed. 

The whole character of the milk may be 
changed by peptonizing, which prepares the 
casein for absorption and neutralizes the 
acid of the stomach. 

If the top-milk method of modification is 
used the required number of ounces are 
PlP=l|| dipped from a quart bottle by means of the 

I j II Chapin cream dipper, the milk having pre- 

! ' i viously stood for at least four hours on ice. 

By diluting top 10-ounce milk twice, that 
is 1 part top milk and 1 part diluent, a for- 
mula is obtained of fat 3.5 per cent, sugar 
2 per cent, proteid 2 per cent. By diluting 
top 9-ounce milk four times, 3 parts diluent 
and 1 part of milk, the result would give a mixture analyzing 3 
per cent fat, 1 per cent sugar, 1 per cent proteid. 

Thus a number of formulae can be worked out as follows : 




Fi 



39. — Chapin 
Dipper. 



Cream 



Fat 4 per cent 

Sugar 7 per cent |^2) 8% fat 

Proteid 2 per cent 



Dilute 16 ounces top milk twice. 

4% sugar, 4% proteid. 



4% fat 



2% sugar 



Top 16 ounces from quart 

Lime water 

Milk sugar 

Water enough to make 20 ounces. 



2% proteid. 
Ounces 



10 
2 
11 



INFANT FEEDING. 131 

Fat 3 per cent 

Sugar 6 per cent >- 

Proteid 1 per cent 



Dilute top 9 ounces milk 4 times. 

4) 12% fat, 4% sugar, 4% proteid. 



3% fat, 1% sugar, 1% proteid. 

Ounces 

'Top 12 ounces from quart 6| 

Lime water 2 

Milk Sugar 1 

Water enough to make 20 ounces. 

Fat 1.50 per cent 1 

Dilute top 9 ounces milk 8 times. 

Sugar 5 per cent 



j 8 ) 12% fat, 4% sugar, 4% proteid. 

Proteid .50 per cent J 1.50% fat, .50% sugar, .50% proteid. 

Ounces 

Top 12 ounces milk 2-J- 

Lime water 2 

Milk sugar 1 

Water enough to make 20 ounces. 

Sugar. — By adding 1 ounce of milk sugar, a little less of 
cane sugar, to 20 ounces of the solution the sugar content 
is brought to 6 per cent. Three level tablespoonfuls of milk 
sugar equals 1 ounce in weight, or 2 level tablespoonfuls of 
cane sugar. 

Additional formula can be found in the appendix. 

Condensed Milk. — This milk is unfit for long-continued feed- 
ing because of its large carbohydrate content and small fat con- 
tent. It is made by evaporating, at a low temperature, a 
sterilized cow's milk in large vacuum pans to about one- 
fourth its volume, after which is added about an equal amount 
of cane sugar which acts as a preservative. The unsweetened 
condensed milk, termed ''evaporated" will quickly spoil if the 
can is left open. The following is an analysis of condensed 
milk: 

EAGLE BRAXD. 1 

Percent. 

Fat 8.8 

Sugar 52 . 2 

Total proteid 9.3 



•9 O 



/ - 



Total solids 

Ash 1.9 

Water 27.8 



1 Soudern : Kerlev, Treatment of Dise.ise.s of Children. 



132 



THE DISEASES OF CHILDREN. 



The following analyses are given by Chapin, from the United 
States Department of Agriculture : 



„ O < ^ 

6 og 



4.00 
3.50 
5.00 



0.70 
86.80 



CONDENSED MILK 
J'ER CENT. 



Fat 8.44 

Proteid 7.23 



53.21 



^ ( cane, 41.52 / 

^^g'^^" I milk, 11.69] 

Salts 1.80 

Water 28.14 



CO 








COiH 


WTjH 


M (M 


M^ 


^ 


•E-r-l 


HtH 


^ '-' 


^8h 


^o^- 


^.EH- 


bop^- 


p.^:^; 


f^^^ 


^E^^ 


^^^ 


-J f^ 


pa 






IC^ Q 


COrH a 


iHrH O 


n.-^ ^ 




iH 


1— 1 




P^tf 


« K 


« w 


M « « 


rt g w 


M H w 


rt H H 


W H &q 


Eh !;:^ S 


Eh Eh Ph 


Eh H Pl, 


H Eh Ph 




5-^ 


M <J 


f <! 


^^ 


^^ 


PES 


0.84 


53 


0.60 


0.70 


0.45 


0.52 


0.60 


0.72 


3 33 


3.80 


4.43 


5.32 


0.11 


0.13 


0.15 


0.18 


95.58 


94.95 


94.12 


92.94 






fi^ 



1.05 
0.90 
6.65 



0.22 
91.18 



Owing to the thickness of condensed milk, and the varying 
sizes of spoons, it is difficult to dilute condensed milk accurately. 
If a teaspoonful of condensed milk is removed from the can, 
without allowing it to drip until the spoon is level full, it will 
contain fully a teaspoonful and a half. Hence, when measuring 
condensed milk, each spoonful should be allowed to drain until 
it does not drip, and its bottom scraped off on the can before 
adding the water. The same spoon should be used to measure 
the water also. 

The reasons for its popularity among the poor is that it is 
cheap, is easily prepared, and does not spoil as quickly as 
ordinary milk. 

From the analyses given it can readily be seen that the fat 
percentage in any dilution, even 1 to 8, is much too small, and 
the mixture in this strength, 1 to 8, is sickening sweet. 

As a substitute feeding in difficult feeding cases a weak dilu- 
tion of condensed milk is of great value, but it does only as a 
temporary food. If used for some time the fat content can be 
increased by the addition of a drachm or so of top milk, the 
gradual resumption of cow's milk being attained in this way. 

Kerley has suggested the administration of cod liver oil to 
augment the fat in condensed milk. 

Children fed on condensed milk are usually fat, but flabby, 
and have little resistance to acute illness. 



INFANT FEEDING. 133 

Peptonized Milk. — In a milk which has been peptonized the 
proteids have been digested, converted into soluble peptones, 
and this can be accomplished partially or completely. When 
completely peptonized the milk has a bitter taste. When milk 
is used in nutrient enemas it should be completely peptonized, 
as the bowel in this part is not a dig^esting organ, but an absorb- 
ing one. Peptonizing tubes (Fairchild) contain 5 grains of 
pancreatine and 15 grains of sodium bicarbonate. The contents 
of one of these tubes is dissolved in 4 ounces of water and 
stirred into 1 pint of fresh milk. This is then heated from 
105° to 115° F. for 20 minutes. The process of peptonization 
or digestion can be stopped by placing the vessel on ice or by 
bringing the milk quickly to a boil. If a child is being fed 
upon a modified milk and it is necessary to peptonize it, the 
contents of part of a tube can be added to the bottle before feed- 
ing, and the bottle stood in a vessel of water at a temperature 
of 120° F, and allowed to remain for 20 minutes. It is then 
cooled to the proper temperature for feeding. Peptonized milk 
should never be given over a very long period as it relieves the 
stomach of work which it should be made to do. Completely 
peptonized milk has a distinctly bitter taste. 

Directions for Making Whey. — After removing the cream 
from a quart bottle of milk, the skimmed milk is heated to a 
temperature not exceeding 100° P. and removed from the fire. 
To the heated milk is added two teaspoonfuls of essentia pepsin. 
(N.F.), or a tablespoonful of liquid rennet or a junket tablet. 
As soon as a firm curd has formed this is broken up with a 
fork and strained through a cheese cloth without pressure. 
It should be cooled and kept on ice until used. If milk or 
cream is to be added to the whey after breaking up the curd 
before straining, it should be brought quickly to 150° P., then 
strained, otherwise the added milk will be curdled by the 
curdling ferment remaining in the whey. 

In certain difficult feeding cases, fat-free whey mixtures can 
be used to great advantage. Practically all of the casein has 
been removed, the casein remaining being approximately .35 
per cent. The following analyses from Van Slyke show the 
food value of whey obtained from various grades of milk : 



134 



THE DISEASES OF CHILDREN. 





WHEY. 








FROM POOR 


FROM MEDIUM 


FROM RICH 




MILK 


MILK 


MILK 




CONTAINING 


CONTAINING 


CONTAINING 




3 PER CENT FAT 


4 PER CENT FAT 


5 PER CENT FAT 


Total solids 


6.87 


6.96 


7.38 


Fat 


0.28 


0.30 


0.30 


Total proteids 


69 


0.87 


1.03 


Sugar and ash 


5.90 


5.79 


6.04 


Water 


93.13 


93.04 


92.62 



When in difficult cases a child has thrived for a time upon 
whey, an increase both in the fat and proteid content can be 
had with an addition very gradually of the milk. 

Southworth ^ suggests the following method of making whey 
and of whey feeding: 

Method of Making Cream and Whey Mixtures. — Secure a 
quart bottle of good average milk upon which the cream has 
risen. Remove with the Chapin dipper the upper 5 ounces of 
the cream layer, which, when mixed, will contain about 20 per 
cent of fat, and preserve this for further use. Pour the re- 
mainder of the bottle (about 27 ounces) into a double boiler, 
the lower portion of which contains tepid water, and add 1 
tablespoonful Shinn's liquid rennet, or 1 Hansen's junket tablet, 
or 1 tablespoonful of Wyeth's liquid rennet, or 2 tablespoonfuls 
of essentia pepsin (N. F.). Mix thoroughly. Place a chemical 
thermometer in the whey and heat slowly up to 155° 
(68° C.) to destroy the rennet ferment, which otherwise would 
clot the casein of the cream or top milk when subsequently added 
to the whey. Heated beyond 155° F. the albumin, part of the 
soluble proteids, will be coagulated and the nutritive value of 
the whey reduced. As soon as a solid curd forms cut this cross- 
wise into small pieces with a table knife to facilitate the escape 
of the whey, and while continuing to heat to 155° F. use the 
flat of the knife blade to assemble and press together the pieces 
of curd. This increases materially the yield of whey, and the 
curd finally contracts with heat and manipulation into a rub- 
bery lump the size of the palm of the hand. Straining through 
a wire strainer now gives 20 ounces or more of moderately 
opaque yellowish whey, upon which but little fat rises on stand- 
ing. Adding to 20 ounces of this whey varying amounts of the 



iCai 



Pedialj/'ics. 



INFANT FEEDING. 



135 



top 5 ounces of cream (20 per cent fat), previously removed, 
will give us a series of formulae suitable for most purposes where 
cream and whey mixtures are required. By removing and using 
the top 6 ounces (17 per cent fat) or top 7 ounces (15 per 
cent fat), mixtures may be obtained with a lower fat per- 
centage ; or by using more of these top milks in the mixture 
the same amount of fat with a larger proportion of casein in 
the proteids. 

WHEY AND CREAM MIXTURES, ]\rADE FROM 20 PER CEXT CREAM (TOP FIVE 
OUNCES OF ONE QUART BOTTLE) AND TWENTY OUNCES OF WHEY FORM 
REMAINDER OF BOTTLE. 





FAT 


SUGAR 


PROTEID 




PER CENT- 


PER CENT- 


PER CENT- 




AGE. 


AGE. 


AGE. 


20 oz. whey -f 1 oz. cream ( 20 per cent fat ) = 


1.00 


5.00 


0.90 


20 oz. whey + IJ oz. cream (20 per cent fat) = 


1.50 


5.00 


1.00 


20 oz. whey + 2 oz. cream (20 per cent fat) = 


2.00 


5.00 


1.10 


20 oz. whey + 2i oz. cream (20 per cent fat) = 


2.40 


5.00 


1.15 


20 oz. whev + 3 oz. cream (20 per cent fat) = 


2.75 


5.00 


1.20 


20 oz. whev + 3 J oz. cream (20 per cent fat) = 


3.15 


5.00 


1.25 


20 oz. whey + 4 oz. cream (20 per cent fat) = 


3.50 


5.00 


1.30 



Any case in which mild stimulation is desired an addition 
of an ounce of sherry wine to a pint of whey is frequently 
desirable and of benefit. 

Ramog'en. — Biedert's Cream Mixture, called Ramogen, is a 
preparation which in certain difficult feeding cases is of some 
service as a temporary food. 

Cow's milk can be added to a Ramogen-water mixture as 
acute symptoms have subsided. The following analyses have 
been given in various dilutions : 







CALORIES 


PERCENTAGE OF 










RAMOGEN. 


WATER. 


IN 100 CO. 


Proteids. 


Fat. 


Carbohydrates. 




13 


25 


0.52 


1.23 


2.7 




11-12 


26-27 


5 3-. 5 6 


1.3-1.36 


2.8-3 




10 


30 


0.63 


1.48 


3.1 




9 


33 


0.7 


1.65 


3.46 




8 


35 


0.77 


1.81 


3.8 




74 


38 


0.81 


1.93 


4. 




7 


41 


0.87 


2.06 


4.3 




6* 


43 


0.93 


2.19 


4.6 




6 


45 


0.918 


2.31 


4.8 




5i 


50 


1.07 


2.54 


5.3 




5 


54 


1.15 


2.72 


5.7 



136 



THE Di;-EASES OP^ CHILDREN. 



The following analyses is given of Ramogen and whole-milk 

mixtures : 



Ramogen. 



MIXTURE OF 


Water. 


Milk. 


12.^ 


2 


12 


3 


11 


34- 


11-S 


4 1 


lO-i 


44 


10 


5 i 


9-i 


5* ^ 


8 


6 I 


8.^ 


64 


8 


7 1 


74- 


74 



Calories 
IX 100 cc. 



30 
33 
35 

37 
39 
41 
43 
45 
47 
49 
51 



PERCENTAGE OF 



Proteids. 


Fat. 


Carbo- 
hydrates. 


0.92 


1.39 


2.5 


1.17 


1.54 


2.8 


1.29 


1.64 


2.88 


1.42 


1.74 


3.0 


1.54 


1.83 


3.12 


1.66 


1 92 


3.24 


1.78 


2.01 


3.36 


192 


2.11 


3.5 


2. 


2.19 


3.6 


2.18 


2.34 


3.76 


2.3 


2.4 


3.9 



Calorie. — A calorie is the amount of heat required to raise 
the temperature of 1 kilogram of water 1° C, which is about 
eciuivalent to the amount required to raise a pound of water 
4° F.. and is used as a unit of measure of food value as ex- 
pressed in terms of heat production. 

Atwater claims that : 

One gram of protein furnishes 4 calories ; 1 pound furnishes 
1920 calories. 

One gram of fat furnishes 8.9 calories ; 1 pound furnishes 
4040 calories. 

One gram of carbohydrate furnishes 4 calories; 1 pound 
furnishes 1820 calories. 

It has been suggested by Heubner. Biedert and others that 
during the first year of life a child should receive about 100 
calories per kilo (2^ pounds) of body weight in 24 hours, i. e., 
for every pound of its weight it should receive sufficient food 
to proA^cle 45 calories of energy. During the next three months 
from 40 to 45 calories per pound, decreasing, until at 12 
months they consume 32 to 35 calories, daily, per pound of body 
weight. The following approximate schedule of infant recjuire- 
ment is oiven bv Heubner : 



INFANT FEEDING. 137 

55 calories for the first week. 

107 calories for 2 to 12 weeks. 

91 calories for 13 to 24 weeks. 

83 calories for 25 to 36 weeks. 

69 calories for 37 to 44 weeks. 

Pierre Budin ^ states that average composition per liter of 
human milk is : 

35 grams of butter. 
74 - 75 grams of lactose or milk sugar. 
12 - 14 grams of proteids of albuminoids. 
2 grams of mineral salts. 
A total of 175 grams of solids. 

He states the most important substance in the maintenance 
of the body heat is butter, as it is the constituent in milk which 
contains the greatest number of calories. One gram of butter 
yields 9.3 calories, and 96 per cent of the butter in milk is 
utilized by the organism. Of the number of calories repre- 
senting the average alimentary ration of an infant, that 53 per 
cent, more than half, come from butter. It is estimated that 
sugar of milk furnishes 29 per cent, and the albuminoids 18 per 
cent of the total calories. 

It has been shown that the energy equivalent of 1 gram of 
fat is 9.1 calories; of 1 gram of carbohydrate 1.1 calories, and 
of 1 gram of proteid 4.1 calories. To calculate the calorimetric 
requirements, determine from the body weight the number of 
calories required. A child often requires 15 calories per pound 
or 450 calories, the first of the equation needed. 

An ounce of whole milk contains 21 calories. 

An ounce of carbohydrate contains 120 calories. 

An ounce of 16 per cent cream contains 54 calories. 

One ounce of skim milk contains 10 calories. 

One ounce of flour or cereal contains 120 calories. 

One ounce of cereal water contains 2 or 3 calories. 

The number of calories in the mixture can be obtained from 
multiplying the number of ounces of the various individual 
ingredients in the mixture bv the above figures and adding the 



1 "The Nursliiiff." 



138 THE DISEASES OF CHILDREN. 

results together to find the energy quotient of the mixture. 
Divide the total number of calories by the number of pounds 
and multiply this result by 2.2 to get the number of calories 
per kilogram. 

Diluents in Milk Formulae. — Because of the fact that the 
casein of cow 's milk coagulates in such large masses in the process 
of digestion, it has been suggested that the addition of a cereal 
decoction will enable the stomach juices to coagulate the casein 
mixture into the smaller fiocculi like mother's milk. In order to 
determine the capacity of an infant to digest starch, Kerley 
made a large number of stool examinations which showed con- 
clusively that the majority of infants of any age are able to 
digest starch. He says "that starch foods may be added with 
benefit to infant-milk foods in a great majority of cases, and 
that they may be used with benefit as a substitute for these foods 
in illness is established beyond all question, both experimentally 
and clinically." The addition of a dextrinizing agent to any 
of the cereal decoctions is to be recommended, among which may 
be mentioned plain maltine and cereo, the latter made by the 
Cereo Company of Tappan, New York. One teaspoonful of 
cereo to the pint of cereal gruel will completely dextrinize it 
and render it more easy of digestion and absorption. As to 
the use of dextrinizing agents, authorities differ, Koplik not 
advocating their use, except in cases in which it is demonstrated 
that the infant is not taking care of the plain decoction. In 
certain marasmic infants in which the percentage method of 
feeding has failed, Keller's method of dextrinizing gruel may 
be tried. 

Directions for Making Malt Soup. — The following description 
of a malt soup is given by Keller, as used at the University 
Children 's clinic in Breslau : 

Three and a half ounces of malt soup extract are added to 
500 cc. of water, or 1 pint, and dissolved. This is solution No. 
1. Then suspend 3 ounces (in measure or 2 ounces in weight) 
of wheat flour in 500 cc, 1 pint of milk, so that the solution is 
quite uniform. The milk and flour solution is then strained 
through cheese cloth. The solution of malt extract and that 
of the milk and flour are mixed together, put into a common 



INFANT FEEDING. 139 

vessel and brought to a boil, being stirred constantly over a slow 
fire. After about 20 minutes of stirring the whole mixture is 
brought to a boil to stop all processes of digestion. The mixture 
is now put up in bottles, each containing about 6 ounces, corked, 
and kept cool. This mixture contains dextrinized cereal and 
malt sugar in addition to the proteids of the milk. Loeflund's 
malt soup extract contains maltose, 57 per cent; dextrine, 12.4 
per cent. Wheat contains 66.8 per cent of starch, 7.5 per cent 
of dextrine, and a small amount of dextrose. By the action of 
the ferments in the malt extracts — principally diastase — the 
starches are converted into sugars. By this method a number 
of easily-assimilable substances are introduced into the economy. 
The action of these processes on the casein coagulation seems 
favorable to its assimilation. 

This malt soup preparation is recommended in subacute 
enteric catarrh in which milk in simple dilution is not assim- 
ilated. Dr. Keller claims that the acid intoxication which is 
present in marasmic infants yields to the administration of this 
malt soup. He found the food of most value in atrophic infants 
from 6 to 7 pounds in weight, and in infants who after the 
twelfth month either refuse to take milk food in any form or 
do not thrive and are stationary in weight. After increasing 
in weight and taking the foods for two or three months, it is 
best to take them off the food gradually and accustom them to a 
modified milk. The chief difficulty in the way of the use of 
this food is its cost. 

Directions for Making Gruels. — Dissolve a tablespoonful of 
cereal flour in small quantity of water, making a smooth paste, 
add water to make a quart. Place this in a double boiler, 
stirring occasionally, allowing it to cook for fifteen or twenty 
minutes. Only a double boiler should be used as in an open 
vessel the gruel is easily scorched. If the cereal grains are used, 
soak two tablespoonfuls in enough water to cover them for ten 
minutes, pour off this fluid, and add one quart of water, pro- 
ceeding as if the flour was used. The gruel after being boiled 
is strained through a coarse meshed cloth, or fine wire strainer, 
and enough boiled water added to bring the amount to a 
quart. 



140 THE DISEASES OF CHILDREN. 

To dextrinize the gruel cool it below 140° F., before adding 
the dextrinizing agent as its diastatic properties are destroyed 
above that teraperature. Cool the gruel and keep on ice until 
used, making a fresh supply at least every second day. 

Ladd ^ has shown that the decoction made by using 2J ounces 
of either barley or oat flour to a quart of water, cooking for 30 
minutes and adding sufficient water to make 1 quart, yields 
about 3.50 per cent of starch, and is as thick a solution as can 
conveniently be strained. This 3.50 per cent decoction has there- 
fore been adopted as the stock solution in the milk laboratories. 

On this basis the amount of stock cereal decoction to be added 
to a mixture of modified milk to obtain any percentage of starch 
can be calculated by the formula. 

By using 3 ounces of the flour to a quart of water, the stock 
solution of cereal gives 4.5 per cent of starch, and if straining 
the solution is dispensed with, higher percentages can be given 
than in the above table, 4.50 being substituted for the denomi- 
nator, 3.50. An ounce of flour by measure is practically the 
same as by weight. 

Junket. — This is made by coagulating the casein of cow 's milk 
by the addition of Fairchild's essence of pepsin, rennet, junket 
tablet or essentia pepsin (N. F.). One teaspoonful of pepsin is 
gently stirred into a pint of fresh, clean cow's milk and the 
milk brought to a temperature of 115° F. for about 20 minutes. 
It is then removed from the stove and when a thick curd has 
formed it is broken up with a fork and can be served with or 
without sugar. One teaspoonful of sugar can be added. 

Protein Milk. — The preparation of protein milk might be 
mentioned to advantage. The buttermilk from which it is made 
is from a Pasteurized skim milk containing 1.75 per cent of fat. 
To one quart of this is added one ounce of buttermilk from 
some reliable dairy. This is allowed to stand for twelve hours 
at a temperature of 70° to 80° F., is thoroughly beaten at in- 
tervals of two to three hours and then placed on ice until used. 
Each day's buttermilk is made from that of the preceding day, 
a smaller amount of stock being needed as time goes on. The 
amount of stock used is determined by the degree of acidity de- 

1 Art-hives of Pediatrics, April 1908. 



INFANT FEEDING. 141 

sired. The junket is obtained as follows : To two quarts of 
skim milk, two Hansen junket tablets are added. After stand- 
ing twenty minutes at 100° F. the precipitated casein is strained 
through a fine sieve with a potato masher. This process of siev- 
ing is facilitated by adding buttermilk to the curd and is con- 
tinued until the curd is thoroughly broken into fine flakes. 
One quart of buttermilk, one quart of water, one grain of sac- 
charin to the quart are added to the curd and the whole thor- 
oughly beaten to form a fine suspension. The requisite of the 
food is the fine flocculent suspension of the curd which depends 
chiefly on thorough sieving. Boiling the precipitated casein is 
of no benefit. The composition of this protein milk is fat 0.8 
per cent, sugar 2.4 per cent, protein 2.8 per cent, and the caloric 
value is 8.5 per cent to the ounce. In administering the milk it 
must not be heated too quickly nor above 90° F., in order to 
prevent tough masses of casein forming. A large hole in the 
nipple is necessary and the feeding should be interrupted and 
the bottle thoroughly shaken every one or two minutes in order 
to keep the casein from settling to the dependent part of the 
bottle while the fluid portion alone is being consumed. 

Albumin Water. — This is made by adding the white of one 
egg to a pint of cold water, stirring sufficiently to cause a 
thorough mixture, but not beating the egg as it is mixed. Owing 
to the fact that the albumin water is a good culture medium for 
bacteria, it is not advisable to use this as a substitute feeding 
in acute dyspeptic or diarrheal diseases in children. 

Beef Juice is prepared by first cutting a piece of lean beef 
into small cubes and while .held upon a fork heated through 
upon a hot plate or pan. The juice is then expressed by means 
of a meat press or lemon scpieezer into a warm vessel. It is 
possible to obtain from 4 to 5 ounces of beef juice from a pound 
of steak. Beef juice may be fed plain or in combination with 
barley water after salting to taste. 

Animal Broths. — These may be made from beef, chicken, mut- 
ton or veal. A pound of meat cut into small parts is boiled 
for about two hours in a quart of water, enough water being 
added from time to time to keep the resultant liquid at about 
1 pint. All of the broths should be strained thoroughly tlirough 



142 THE DISEASES OF CHILDREN. 

a fine colander and allowed to cool; the fat which rises to the 
surface is then carefully removed. As a temporary food they 
are very good, especially in some of the forms of diarrheal dis- 
eases. They contain very little fat, about 1 per cent of proteid 
and nearly 2 per cent extractives. 

Arrowroot Gruel. — This substance has been used as a diluent 
for milk, as it has the same effect in breaking up the casein 
as other cereal decoctions. One teaspoonful of Bermuda arrow- 
root is dissolved in a pint of water, allowing it to cook slowly 
for 20 minutes, stirring constantly, strained and allowed to cool. 

Kumyss is fermented milk, and while sometimes taken by 
older children it is objected to by a majority. Konig ^ gives 
the following analysis of kumyss : 

Water 90.44 

Alcohol 1.91 

Lactic acid 0.91 

Milk sugar 1.77 

Proteid 2 . 44 

Fat 1 . 46 

Ash ...0.142 

Holt recommends the following formula for its home 
manufacture : 

One quart fresh milk, -J ounce sugar, 2 ounces water and 
piece of fresh yeast cake J inch square, put into wired bottles 
and kept at a temperature of 60° and 75° F. for a week. The 
bottles are shaken five or six times a day and then put on ice. 

Buttermilk. — Fat-free buttermilk has been used in difficult 
feeding cases and those convalescent from severe enteric dis- 
turbances with great benefit. Because of the great bacterial 
content of buttermilk from churned milk it has not been con- 
sidered a safe food, but since the introduction of the pure lactic 
acid bacteria in tablet form for the artificial manufacture of 
buttermilk, its use has become more general and the results 
better. 

From a quart bottle of milk the top 12 ounces are removed 
and 12 ounces of water added in which one lactone tablet has 
been dissolved. This is shaken and the bottle kept at a tem- 

1 Koplik. 



INFANT FEEDING. 



143 



perature of 80 degrees until the milk is curdled, when it is put 
on ice and the lactic acid fermentation stopped. This is at first 
given slightly diluted and finally undiluted. Good buttermilk 
contains from 0.5 to IJ per cent of fat; 2.5 to 3.5 per cent of 
sugar; and about 2.5 per cent of proteid. The caloric value 
of buttermilk averages about 400 calories per liter. 

In certain acute intestinal disorders the following method of 
preparation can be employed : In a quart of buttermilk is dis- 
solved two tablespoonfuls of flour and 3 tablespoonfuls of cane 
sugar, heat to boiling, stirring constantly, and cooled. 

Oatmeal Jelly. — Two tablespoonfuls of oatmeal, rolled oats 
or Quaker oats, or oat-gruel flour, to 1 pint of water cooked in 
double boiler three hours, add water to keep the amount 
at 1 pint. Strain through a colander, allow to cool and keep 
on ice. One tablespoonful, level, of the flour equals Y^ ounce. 

Scraped Beef. — A thick, lean steak is heated through on a 
hot griddle. With a sharp knife the browned surface is cut off 
and with a knife held at right angles to the meat, the pulp is 
scraped away, made into a meat ball, again heated through 
and fed after salting to taste. 



1 level tbsp. flour to qt. of 

water 

2 level tbsp. flour to qt. of 

water 

3 level tbsp. flour to qt. of 

water 

1 level coverful flour to qt. of 

water 

2 level coverfuls flour to qt. of 

water 

3 level coverfuls flour to qt. of 

water 

4 level coverfuls flour to qt. of 

water 



Barley. 


Legume. 


Oat. 


Wheat. 




w 




w 




05 




m 




H 




H 




w 




a 




^ 




Eh 




rl 




&H 




< 




< 




< 




< 




» 




^ 




1^ 




Ph 


2^ 


li 


si 


P 




SI 


^1 


u 


^o 


ss 




Sg 


^" 


5g 


a o 


ss 


2f« 


Sm 


S« 


«« 


2 03 


« K 


O n= 


03 03 


M H 


< « 




< H 


< a 


ij S 


< H 


fU CL 


o ei. 


« d, 


O ft- 


Ph h, 


O ftn 


fl, ft. 


O ft, 


0.12 


0.60 


0.19 


0.53 


0.12 


0.60 


0.10 


0.62 


0.24 


1.20 


0.39 


1.06 


0.24 


1.20 


0.20 


1.25 


0.30 


1.80 


0.58 


1.59 


0.36 


1.80 


0.30 


1.88 


0.48 


2.40 


0.78 


2.12 


0.48 


2.40 


0.40 


2.50 


0.96 


4.80 


1.56 


4.24 


0.96 


4.80 


0.80 


5.00 


1.44 


7.20 


2.34 


6.36 


1.44 


7.20 


1.20 


7.50 


1.1)2 


9.60 


3.12 


8.48 


1.92 


9.60 


1.60 


10.00 



144 THE DISEASES OF CHILDREN. 

Percentage Cereal Gruels. — The following analysis is given 
by the Cereo Company of gruels made from their specially-pre- 
pared flours. The top of the package has been designed as a 
measure for the flour. Barley, legume (made from beans), 
oats and wheat are utilized for preparation of flours. From 
the foregoing table can be seen the strength of the gruel when 
larger or smaller quantities of flour are used in the water. 

SYMPTOMS OF DISAGREEMENT OF MILK FEEDING. 

Insufficient Quantity. — Child will cry immediately the bottle 
is empty and will suck on its fists. 

Too Much Fat. — Vomiting will occur very soon after a feed- 
ing ; stools more frequent and thin ; presence of lumps of a 
soft material resembling curds. 

Too Much Sugar. — Thin, green, sour stools with gas passed 
with each; an excoriation of buttocks frequent. 

Too Much Proteid. — Colic; vomiting; curds in action, fre- 
quently in large numbers, either large or small, with much 
mucus mixed or separate. There may be alternating diarrhea 
and constipation. 

Formula Too Weak. — Stationary weight with constipation,. 

Talbot 1 has shown ' ' that the curds in infants ' stools are 
either large curds containing a large per cent of nitrogen and a 
small per cent of soaps; and small curds containing a low per 
cent of nitrogen and a large per cent of soaps." He concludes 
these curds are composed of some proteid, probably casein or one 
of its derivatives, which, on coagulating, entangles the milk fat 
in its meshes. The amount of fat in the curds depends on the 
amount of fat in the milk, and as the fat increases it replaces 
the proteid in the curd. The presence of large curds can be in- 
terpreted as indicating lack of HCl. "The small curds- are 
composed mainly of fat, mostly in the form of fatty acids and 
soaps. There is no evidence that they contain casein-like ma- 
terial, and they have, like the normal stool, a low percentage of 
nitrogen. They represent the fat in the stool rather than 
protein. ' ' 



Boston Medical and Surgical Journal, January 7, 1909. 
Boston Medical and Surgical Journal, June 11, 1908. 



INFANT FEEDING. 145 

The large casein curds witli shiny envelope can be prevented 
by heating- the milk to 170° F. before it is given. 

Difficult Feeding Oases. — The above-named symptoms may be 
present successively as the case progresses and each must be 
met by appropriate measures. As before stated, one must not 
attempt to adapt a formula to a certain age. Each child must 
be a law unto itself. A weak formula in all its ingredients must 
first be given, even if the digestion has been entirely normal, 
though it be at the sacrifice of several ounces in the child's 
weight, rather than upset the child's digestion by a strong mix- 
ture, and not be able to get it back on a gaining formula for 
some time. 

The first formula should contain less than 2 per cent of fat 
and less than 1 per cent of proteid, and this may be increased 
daily or eveiy other day until the child appears satisfied and 
evidences a gain in weight. It is the proteid content which will 
cause the most trouble with the majority of difficult cases, though 
fat intolerance is freciuently seen. I have had under my care 
one child who, from six months to one year of age, could not 
be gotten up beyond 3 per cent of fat, the prescription upon 
which she thrived best being fat, 3 per cent; sugar, 6 per cent; 
proteicls, 2 per cent. 

To aid the digestion of the casein, and to assist in its break- 
ing up in small flocculi, several measures have been advocated. 
PojTiton of London suggested the use of citrate of soda in the 
proportion of 1 grain to the ounce of milk. He claims that 
sodium paracasein is formed which is absorbed as a fluid. Cot- 
ton of Chicago has advocated its use also. The soda is not an 
alkali but an alkali is needed for the purpose of assisting in 
breaking up of the curds, and to favor the production of hydro- 
chloric acid, hence the importance of the addition of lime water 
to the formula. Rotch claims the soda decalcifies the casein, it 
is then not affected by rennet forming with the acids of the 
stomach, soft, friable fiakes of the buttermilk type. 

The following case is an example of this difficult feeding 
class : 

Child born after normal labor of short duration; mother primipara, very 
nervous temperament, anemic; abundant supply of milk at first but gradual 



146 THE DISEASES OF CHILDREN. 

failure; history in child of slight jaundice; colic, crying all the time; curds 
and mucus in movements; had been taken off of breast milk and given 
successively malted milk, barley water and malted milk, barley water and 
panopepton, albumin water and malted milk, albumin water, Ramogen. 
Five weeks old when I saw it first; constant crying; tense abdomen; given 
2 teaspoonfuls of olive oil and put on a dextrinized gruel and whey, equal 
parts, 2 ounces every two hours. The first night it slept all night, had 
two movements, well digested. On third day it was given a mixture of 
whey, 2 ounces, and barley water, ^ an ounce, and was nursed by the 
mother twice, with a bottle after each, when about half quantity was taken. 
On fourth day was put on modified milk fat 1.5 per cent, sugar 6 per cent, 
proteid .8 per cent. Gained 10^- ounces the first week and in every way 
seemed normal. 

The history of this case is a counterpart of a number that 
are seen, and unless the child has already developed into an 
athreptic or marasmic state this plan will usually bring good 
results. 

At the first sign of disagreement discontinue the milk mix- 
ture and give one of the cereal dococtions; after a few days try 
a small amount of whey with the cereal ; then add milk gradually. 
If cow's milk in this form cannot be assimilated, try condensed 
milk as a temporary food, beginning this with a dilution of at 
least 1 part to 20 or 24. Top milk may very tentatively be 
added to the condensed milk and gradually increased, and in this 
way get on to a gaining formula. 

Care of Milk for Journey. — One is frequently asked to sug- 
gest a method of preparing milk for a journey. I recently had 
a box fixed for two children starting for Mexico. A wooden 
box was built around an ordinary galvanized delivery tray hold- 
ing 4 quart bottles, a handle and hasp being soldered on. The 
4 quart bottles were surrounded with ice and instructions given 
as to change of ice by car porters en route. Certified milk was 
sent, and word received from travelers at journey's end reported 
milk sweet and unchanged. If a modified milk formula had 
been required for either of these children it could have been 
prepared and placed in nursing bottles or a quart Mason fruit 
jar with screw top, and the bottle shaken before each feeding 
was poured into the nursing bottle. 

Diet After the First Year. — Milk should be the basis of a 



INFANT FEEDING. 147 

child's diet for the first 12 months. Weaning (see page 99) 
should be begun before the twelfth month, and artificial feeding 
be complete, or nearly so, at that time. At 10 or 11 months 
of age one feeding a day can be given of strained oatmeal, 2 or 
3 tablespoonfuls, over which is poured some of the modified 
milk. With the advent of the first six or eight teeth, an occa- 
sional piece of toast or zwieback can be given the child to 
chew on. 

Only one new article of diet should be given at a time, for if 
the child takes two new ones and is upset, unless passed undi- 
gested, the disturbing cause would not be known. 

Regularity of feeding should be positively insisted upon, and 
the habit of between-meal eating ' ' stopped before it has begun. ' ' 
Nothing but water should be given between meals. The habit 
of continuing night feedings until the second year should never 
be allowed. 

Too much emphasis cannot be placed on the necessity for 
thorough and prolonged cooking of cereals for infant feeding, 
especially oatmeal. 

While it is a pleasure but few parents wdll deny themselves, 
a young child should not be allowed at the table at the family 
meal times. The temptation to give the child a taste of this 
or that is too great to be resisted. 

Fruit juices should be given before the end of the first year, 
orange being usually most enjoyed. It should not be given too 
close to a milk feeding. After the first year prune juice, if not 
too sweet, can be given. 

The following diet lists are suggested as a guide for feeding 
after the first year: The first feeding in morning and last 
feeding at night are usually milk, and the child at this age 
requires more than can be held in the ordinary bottle, which 
is made to contain 8 ounces. Whitehall-Tatum Company manu- 
facture a 12-ounce bottle, and at my suggestion the Hygeia 
Nursing Bottle Company have begun to manufacture a 12- 
ounce Hygeia bottle, which will be found a great convenience, 
obviating the necessity of preparing two bottles for each feeding. 

Fro7n Tivelfth to Fifteenth Month. — Five meals a day. The 
first meal, 6.30 to 7.30 a. m., 8 or 10 ounces of milk; 10 a. m. : 



148 THE DISEASES OF CHILDREN. 

Strained oatmeal jelly, 2 or 3 tablespoonfuls with 4 or more 
ounces of milk in addition, or soft-boiled egg not oftener than 
three times a week. Noon : Juice of half an orange. 1 o 'clock : 
Scraped beef and bread crumbs, or rolled zwieback or 4 to 6 
ounces of animal broth, with zwieback or Holland rusk. 4 p. m. : 
Bread and milk. 7 p. m. : bottle of milk. 

From Fifteenth to Eighteenth Month. — To the above list may 
be added the cooked fruits, as prunes, not too sweet ; the inside 
of a baked apple or apple-sauce ; thoroughly cooked-rice ; boiled 
or baked potato; junket; finely-minced mutton chop. . 

From Eighteenth Month to Third Year. — During this period 
other vegetables may be added gradually, as spinach, asparagus 
tips, stewed celery, baked potato, peas, beans, fish, thin crisp 
bacon, minced chicken or turkey, roast beef, cream, crackers, 
bread and butter. 

Sample diet list from sixteenth to eighteenth month : 

Breakfast, 7 a. m. Strained oatmeal, 2 or 3 tablespoonfuls, 
and cream, or barley gruel, and cream with 8 ounces of whole 
milk. 

Second Meal, 10.30 a. m. Milk and stale bread, or cracker, 
rusk or zwieback. 

Third Meal, 1.30 to 2 p. m. Any of the following: Soft-boiled 
eg^ (water boiled vigorously, removed from stove, and egg 
dropped in for two minutes), with broken toast or zwieback; 
(b) 8 ounces of animal broth (beef, mutton or chicken) ; (c) 
a teacupful of junket with milk; (d) thoroughly-cooked rice, 
and milk. Stewed prunes can be given with this meal. 

Fourth Meal, 5.30 to 6 p. m. Bread and milk. Fruit juices 
are given between meals, as suggested in previous lists. 

To be Avoided. — Candy should not be given to children under 
three years of age, and very sparingly after that time. Sweets of 
all kinds cause a tendency to develop a pharyngeal trouble such 
as tonsillitis and frequent attacks of '' colds " and bronchitis. 

Proprietary Foods. — The fact that there are upon the market 
almost countless numbers of baby foods is evidence enough that 
none answers the requirements in all cases. These foods may be 
divided into three classes ; first, the so-called milk foods to which 
water is added, and those foods in the form of powder which 



INFANT FEEDING. 149 

have been suggested as modifiers of milk. The latter are added 
to milk for their influence upon the casein. Second, the so- 
called Liebig or malted foods, and third, the farinaceous foods. 
In the second class the starches are supposed to have been 
entirely converted into soluble sugars by the diastatic action 
of the malt. In the third class but a small portion of the starch 
is converted by the process of cooking. 

Among the first class may be mentioned condensed milk and 
evaporated cream, Prof. Gartner's mother's milk and Ramogen, 
Mellin's Food and peptogenic milk powder. In the second 
group, the malted foods, are Nestle 's food and malted milk. In 
the third class a farinaceous or dextrinized food is Imperial 
Granum, which may be temporarily used alone or in combina- 
tion with milk. 

Mellin's food is used with milk as a modifier, it being claimed 
that it acts as an attenuant to the curds of cow's milk. 

Peptogenic milk powder is used with milk and the mixture 
submitted to heat. By this process the proteids are converted 
into absorbable peptones. Nestle 's food and malted milk when 
diluted are deficient in fat and proteid. 

Gavage. — This method of feeding is a valuable one in certain 
classes of cases in which a child will not eat or is too weak to 
do so, or in which vomiting occurs immediately after food is 
taken. The same steps are taken as in stomach washing (see 
page 82). The food mixture is poured into the funnel and 
when it has been seen to pass the glass tube connecting the 
catheter with the rubber tube, the catheter is compressed tightly 
and quickly withdrawn. Gavage may be performed with the 
patient in a recumbent position or held upright in the nurse's 
lap, leaning against her shoulder. The writer had the pleasure 
of observing the cases at the New York Infant Asylum when 
an interne there, reported by Dr. Kerley in the ArcJiivts of 
Pediatrics^ February, 1901. It was found in these cases, many 
of them of persistent vomiting, that water or food introduced 
into the stomach through the tube was retained when a very 
much smaller quantity given by the mouth from a spoon or 
bottle would not be retained. Young children stand the intro- 
duction of the tube without discomfort, and gavage can be used 



150 THE DISEASES OF CHILDREN. 

for a very much longer period of time than rectal feeding can 
possibly be tolerated. A very weak-modified milk, plain or 
peptonized, cereal decoctions, the concentrated foods, as pano- 
pepton and stimulants, may be given in this way. In cases of 
diphtheria or those wearing an intubation tube, the stomach tube 
is best introduced through the nares. 

Rectal Feeding. — This method of nourishment is a valuable 
one when all others have failed, and may be the means of tiding 
over a desperate case until nourishment can be given in other 
ways. The food for administration in this way should be as 
near as possible free from fat and completely peptonized. Com- 
pletely peptonized or pancreatized skimmed milk, mixed with 
albumin water of double strength, namely, the whites of two 
eggs and a pint of water, can be used to advantage. This should 
be heated to about 100° F. as it loses several degrees of heat 
in its passage through the tube of the fountain syringe, if this 
syringe is used to insert it. The food is best inserted through 
a small-size short rectal tube (No. 14A) which can be attached 
to a small rubber tube of the fountain syringe, or the fluid can 
be injected with a hard rubber or glass piston syringe; care 
must be taken to invert the syringe to be sure that all of the 
air is first expelled. The child is placed upon its left side, hips 
elevated by raising upon a rubber-covered pillow, its thighs 
flexed upon its abdomen much as in the Sim 's position ; the tube 
is anointed well with vaseline from a tube, and the external 
sphincter also greased. The tube is then inserted slowly to the 
distance of 9 or 10 inches and the nutrient enema slowly injected. 
Not more than 3 ounces should be injected in a child of six 
months of age, nor more than 6 ounces in a child of three 
years of age. After the injection the tube is compressed and 
quickly withdrawn, and the child's buttocks compressed firmly 
and the child held in the original position, if possible; if not, 
it is allowed to lie upon its back with legs and thighs flexed. 
These enemas can be given as often as three or four times in 
24 hours, but if given much of tener than this the bowel soon 
becomes intolerant and they are expelled as soon as introduced. 

In this connection might be mentioned the great benefit 
obtained from the high colon injection of water in cases of 



INFANT FEEDING. 151 

deficient kidney excretion, as the absorption from the colon is 
both rapid and prompt. The method of Murphy suggested 
originally for use in septic peritonitis in both adults and chil- 
dren, viz., the continuous rectal injection may also be employed 
to advantage. It might be well before the injection of the 
nutrient enema to give a preliminary colon irrigation to 
thoroughly cleanse the lower bowel and render it more absorbent. 



CHAPTER VIII. 

DISEASES OP THE NOSE, THROAT AND LARYNX. 
ACUTE RHINITIS. 

Synonyms. — Coryza, acute nasal catarrh, snuffles. 

Etiology. — The most frequent cause of this condition is a 
growth of adenoid tissue in the nasopharynx. Its occurrence 
in infants is comparatively frequent, and in the presence of 
acute symptoms in the nose the nasopharynx should be inves- 
tigated. Congenital deformity of the nose, or deformity result- 
ing from an injury may mechanically act as a predisposing 
cause. 

Exposure of the child, being uncovered at night, with a wet 
napkin, may cause trouble because of the extra work thrown 
upon the air passages from interference with the skin by chilling. 

Pathogenic organisms are a potent factor, as a dust-laden air. 
A child should never be kept in a room which is being swept. 

Pathology. — The entire mucous lining of the nose is much 
congested and swollen, due to an increase in the size of the 
blood vessels and infiltration of lymphocytes in surrounding 
tissues. A watery secretion is at first thrown off, followed by 
a mucopurulent one. 

Symptoms. — There is at first sneezing and rubbing of the 
nose; restlessness and difficulty in breathing through the nose. 
This is specially true in infants when nursing, breathing being 
much interfered with because of the swelling of the nasal 
mucous membrane. Occasionally there is a slight rise of tem- 
perature, rarely more than 2° P. There may be a swelling of 
the submaxillary glands. If the discharge is profuse there may 
be an excoriation of the skin of the upper lip with a forma- 
tion of crusts or scabs at the nares. 

Diagnosis. — The possibility of a nasal diphtheria developing 
primarily should be borne in mind, and a careful inspection 

152 



DISEASES OF THE NOSE, THROAT AND LARYNX. 153 

of the nasal mucous membrane made for the presence of a 
pseudomembrane. The nose on examination will be found 
occluded, the red and swollen turbinal tissues touching the 
floor and septum. 

If the condition does not respond to treatment and becomes 
chronic, the possibility of its being a manifestation of congenital 
syphilis must be borne in mind. 

Treatment. — Calomel, gr. i to a nursling in one dose, or in 
repeated small doses, or a castor oil purge, will prove beneficial. 
There is no contraindication to air, but there should be no 
draughts. Unless it be very cold, the child does much better 
if out of doors in a protected perambulator. 

A 50 per cent boracic acid solution, as an irrigation, is of 
benefit. This should be followed by a weak boracic acid and 
vaseline ointment, gr. i to g i, applied to the nasal mucous mem- 
brane on a cotton swab. In older children an oily spray of 
benzoinated albolene is of benefit. Adrenalin solution, 1-5,000 
applied to the mucous membrane by a cotton swab is beneficial. 
A few drops of a 2 to 4 per cent argyrol solution is helpful also. 

The use of cold spinal douches is of great benefit in pre- 
venting attacks in children predisposed to them. An effectual 
method of applying cold, to the chest and back is by Avringing 
a sponge or coarse washcloth out of cold water and rubbing the 
skin back and front as far as the waist each morning, followed 
by a brisk rub. 

CHRONIC RHINITIS. 

This form is rare in children and follows the acute fre- 
quently or may appear as a manifestation of rachitis, adenoids, 
nasal polypi, which are very rare in children, or any general 
condition of impaired nutrition. A nasal discharge from one 
nostril should always make one suspicious of a foreign body 
in the nose. 

The removal of the cause of the chronic form is usually fol- 
lowed by relief unless there is a hypertrophy of the turbinate 
bones. The treatment is essentially that of the acute variety; 
antiseptic sprays and douches, Seller's and Dobell's solutions 
are of s^reat benefit. 



154 THE DISEASES OP CHILDREN. 

ATROPHIC RHINITIS. 

Atrophic rhinitis is found in children with comparative fre- 
quency, oftener in females than males, and begins more fre- 
quently at about the age of 12, though it may begin earlier. It 
rarely begins after adult life is reached. 

There is a chronic nasal catarrh, often involving the pharynx 
and larynx. 

Etiology. — The exact cause is not known. Anemia, unhy- 
gienic surroundings are causes. One of the latest theories is 
that it follows accessory sinus disease, as it is frequently asso- 
ciated with sinus disease. 

Symptoms. — There is a thick yellowish discharge, which dries 
quickly, forming thick crusts. These and the discharge beneath 
have a very disagreeable odor, this being known, as in adults, 
as ozena. This odor is characteristic and peculiar to this condi- 
tion, the patient not being, as a rule, cognizant of it at all. The 
child does not breathe readily through the nose because of the 
crusts. Epistaxis is common from dislodgement of the crusts 
following picking of the nose. The facies is much the same 
as found in uncomplicated adenoids, aprosexia, and they fre- 
quently complicate this form of catarrh, in about 5 per cent 
of cases. Hypertrophy of the turbinates is also present in 
about the same percentage of cases. Otitis media is a compli- 
cation met in about 10 per cent of cases. 

Prognosis. — This is bad, as far as a cure is concerned. Some 
cases recover spontaneously. 

Treatment. — Attention to all abnormal conditions of the nasal 
mucous membrane as soon as diagnosed is most important as a 
prophylactic. Active treatment in the form of cleansing sprays 
may be ineffectual because of the tenacity of the crusts. Dobell's 
and Seller 's solutions or the following : 

Sodii bicarb. 
Borax. 
Table salt. 
Equal parts. 
S.: One teaspoon to a tablespoonful in a quart of boiled water, one-half 
to be used in each nostril. 

These solutions are best used in a fountain syringe. 



155 

If the odor is bad permanganate of potash, 2 grains to the 
pint of water, can be used in the same way. 

If the patient is old enough, and is tractable, office treatment 
is efficient. Applications can be made, consisting of iodine, 
2 per cent in glycerine, or ichthyol or nitrate of silver solution, 
2 per cent, with massage of turbinates. Plenty of fresh air, 
tonics, iodide of iron, etc., are specially indicated. 

EPISTAXIS. 

A hemorrhage from the nose. 

Etiology. — Trauma is the most frequent cause, though it may 
be a manifestation of a general condition, as in typhoid fever, 
scorbutus, hemophilia. Nosebleed may be the first symptom 
of adenoids, being due to the intense congestion of the turbinals, 
which' is secondary to the adenoid growth. 

Older children who have suffered from a rhinitis pick the 
nose to remove encrustations, and abrasion of the mucous mem- 
brane frequently results, causing more or less bleeding. Young 
girls who have a very heavy suit of hair are prone to have fre- 
quent hemorrhages from the nose. 

Rarely it may be a manifestation of puberty as a vicarious 
menstruation. 

Symptoms. — Hemorrhage from one or both alae is the prin- 
cipal symptom, or if it is at all severe the symptoms of acute 
anemia will result. If the bleeding is from the posterior nares 
but little blood will escape from the anterior nares, but will be 
spit up or swallowed. Vomiting always follows this. 

Treatment. — The nares should be cleansed and with good 
illumination they should be closely examined for bleeding areas, 
which can frequently be found upon the septum. An applica- 
tion of chromic or trichloracetic acid or 20 per cent solution of 
nitrate of silver upon a cotton-tipped applicator to the bleeding 
point will usually suffice to arrest it. In the milder forms tannic 
acid, and often adrenalin will suffice. The galvanic cautery is 
most satisfactory if patient can be controlled. It may very 
rarely be necessary to pack the nares with a cotton pledget. 

Lemon juice applied to the mucous membrane is an efficient 
styptic agent. 



156 



THE DISEASES OF CHILDREN. 

NASAL POLYPI. 



These growths, which usually arise from the middle turbinate 
bones, are infrequent in infants, but sometimes found in older 
children. They usually have a pedicle much smaller than the 
body of the polyp. 

Not infrequently the mucous membrane covering the lower 
and anterior border of the septum is hypertrophied and causes 







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Fig. 40. — A. Crypts, very irregular and uneven. Cross-section of human tonsil, 
age 11 years, dissected out in capsule. XIO. Moderately hypertrophied with 
greatly dilated crypts filled with detritus. (Courtesy Dr. Harry A. Barnes.) 

an obstruction to the nares much like that from a polyp. These 
polypi may be papillomatous in character, cystic or fibrous. 

Symptoms. — No symptoms are usually present until the polyp 
is of such size as to mechanically interfere with the breathing 
when they are those of a rhinitis. There is a discharge from the 
nose and inability to breathe with freedom through the affected 
side, headache and restlessness at night. 

Treatment. — The polyp should be removed early. It may be 
accomplished by means of the snare, forceps or excision, the 
snare being preferred. 

DISEASES OF THE TONSILS. 

Too much emphasis cannot be placed on the importance of a 
consideration of the tonsils in childhood. They bear an impor- 
tant relationship to many of the severe illnesses of that age, 



DISEASES OF THE NOSE, THROAT AND LARYNX. 157 

as they are the port of entry of many specific organisms to the 
lymphatic and general circulation. 

The tonsils are situated between the pillars of the fauces, 
and are a collection or masses of lymphoid tissue, which have 
within them a number of crypts. These crypts are lined with 
squamous epithelium. 

The tonsillar membrane is easily infected and the subsequent 
inflammation results in great swelling of the tonsils, and in 
many cases a rapid exfoliation of the epithelia in the crypts, 
which with the fibrin and serum rapidly fill up the crypts, the 
swollen tonsil being dotted with yellowish-white spots. In the 
catarrhal variety of tonsillitis the crypts are ^mpty, the exfoli- 
ated epithelia being thrown off. Occasionally the crypts contain 
a small concretion of broken-down cells and serum in a hardened 
mass, which decomposes, giving to the breath a most disagreeable 
odor. 

The relationship between tonsillitis and rheumatism has been 
referred to elsewhere. The local manifestation of this general 
condition should always be borne in mind. 

TONSILLITIS. 

Two forms of tonsillitis can be considered, the acute catarrJial 
and follicular. 

Acute Catarrhal Tonsillitis. 

Etiology. — This variety is more often seen as a manifestation 
of rheumatism. Exposure to cold, wet feet, and indiscretions 
in diet are the most frecjuent causes. Children who are fed 
sweets indiscriminately are especially prone to develop tonsil- 
litis. Crowded school and sleeping rooms with improper ventila- 
tion is frequently a contributing cause to this condition. 

Symptoms. — The first symptom may be a chill or perhaps an 
elevation of temperature. The child will, more than likely, not 
complain of its throat at all, or perhaps only when it swal- 
lows. It may have pain or discomfort in its joints, manifested 
only by crying Avhen moved or handled. 

Food is frequently refused, due chiefly perhaps to the pain 
in the throat, which is not otherwise complained of. 



158 THE DISEASES OF CHILDREN. 

The temperature is always elevated, it may be to 103° F., 
which lasts for two or three days, gradually subsiding. There 
are remissions but it does not reach normal. Because of the 
infrequency of complaint in regard to the throat from both 
infants and children no examination should be considered com- 
plete without a thorough inspection of the throat by either a 
good direct light or a reflected light from a head mirror. 

The inflammatory process is rarely limited to the tonsils, as 
there is a more or less extensive involvement of the pharyngeal 
mucous membrane. 

The tonsils will be found enlarged, very red and granular 
in appearance, and if the child gags when the tongue is de- 
pressed the tonsils may approximate in the center. 

The bowels are usually constipated and it is not unusual for 
vomiting to occur at the onset. 

Prognosis. — This is good in an uncomplicated catarrhal ton- 
sillitis, but the danger is always great of an infection occurring 
of the tissue behind the tonsil, and the formation of a localized 
abscess. The occurrence of frequent attacks of catarrhal tonsil- 
litis is suggestive of a rheumatic diathesis. 

Treatment. — An initial dose of calomel in all tonsillar and 
pharyngeal inflammations is a positive indication. The dose 
should be larger than is ordinarily given children, at least 2 
grains for a child two years old. This should be followed by a 
dose of aromatic cascara, milk of magnesia or other palatable 
laxative. 

One of the salicylates should be given, preferably aspirin, in 
dose of 3 grains at three- or four-hour intervals to child of three 
years. 

Locally an astringent application should be made to the ton- 
sils, as Loeffler's solution or tannic acid: 

loeffler's solution. 
I^ Mentholi 10 gm. 

Toluene q. s. ad 36 cc. 

Add. 

Creolin 2 cc. 

Liq. ferri chloridi 4 cc. 

Alcoholis q. s. ad 100 cc. — ^M 



DISEASES OF THE NOSE, THROAT AND LARYNX. 159 

A cold, wet compress applied to the throat is of great benefit. 
In very acute inflammations with high fever these may be 
renewed every hour. 

The control of the diet is most important and sweets should 
be eliminated entirely from the bill of fare. 

Follicular Tonsillitis. 

Synonym. — Acute lacunar amygdalitis. 

Etiology. — The streptococcus, staphylococcus and pneumococ- 
cus are probably the most frequent offenders. They gain 
entrance to the tonsillar crypts and there set up a severe inflam- 
mation. 

Exposure to cold or wet, and the rheumatic diathesis are pre- 
disposing causes. 

Age is a factor. It is decidedly more frequent under the age 
of 15 than over that age. Infants under six months of age are 
infrequently affected. Previous attacks act as a predisposing 
factor. 

Symptoms. — The onset is sudden. While a distinct chill is 
difficult to determine in a child it may evidence itself by cold 
and blue extremities, pallor of the face and blanched lips. 

In older children the aching of the joints, back and legs is 
quite severe, but the only manifestation of this symptom in an 
infant may be, as in the catarrhal variety, crying when it is 
picked up. 

The temperature is elevated to 103° F. or 105° F., with re- 
missions of 1° or so, and lasts from three to four days. The 
pulse is correspondingly rapid. In some the respirations may 
be faster as a result of the temperature and toxemia. 

There is anorexia, often vomiting and the boweb irregular. 
During the latter stage there may be thin and green stools from 
the infection following swallowing the mucus from the throat. 
Inspection of the throat shows enlarged tonsils, very red, and 
studded with white spots. These spots are the ends of accumu- 
lations of broken-down epithelium, serum and fibrin in the 
crypts, and as they are squeezed out of the tonsils may coalesce 
on the surface of the tonsil and form a pseudomembrane. 

The pharynx is deeply congested and swollen, and the uvula 



160 



THE DISEASES OF CHILDREN. 



edematous and red also. This condition may be present and 
no complaint of the throat be made, which emphasizes the im- 
portance of a careful examination of the throat in every case of 
illness in a child. Sometimes it is quite painful to swallow. 

The lymph nodes at the angle of the jaw and under the ramus 
may be enlarged. The tonsils can be easily palpated externally. 




Fig. 41. — Osteomyelitis following streptococcic infection from tonsillitis. 
Dr. C. B. Spalding.) 



(Courtesy 



The duration of an attack is usually four or five days, the' 
temperature falls by lysis, the tonsils are clean and gradually re- 
duced in size, and the aching is entirely relieved. 

Complications. — Infection of the middle ear, retropharyngeal 
and retrotonsillar abscess, osteomyelitis . endocarditis may com- 
plicate the convalescence. 

Prognosis. — In uncomplicated cases this is good. 

Diagnosis is chiefly to be made from diphtheria. This fre- 
quently cannot be made without a careful bacteriolpgic examina- 
tion. In suspicious cases a culture should always be made. 
Again a case may begin as an uncomplicated follicular tonsillitis 
and develop into diphtheria. The pseudomembrane in follicular 
tonsillitis can be removed without leaving a bleeding surface be- 
low as occurs in diphtheria. 

Treatment. — Calomel should be given as soon as the diagnosis 
is made, followed by a saline if possible. A portion of a bottle 



DISEASES OF THE NOSE, THROAT AND LARYNX. 161 

of citrate of magnesia can be given usually. Castor oil is also 
of benefit. 

If the child is old enough to gargle a 50 per cent solution of 
peroxide of hydrogen is of great service in softening and remov- 
ing the exudate. Any mild antiseptic solution can be used as 
a gargle, DobeU's and Seiler's solutions are efficient. 

Locally the tonsils should be touched with a mop saturated 
with an astringent solution, as tannic acid or Loeffler's solution. 
The application of powdered aspirin directly to the tonsil 
has been suggested as an excellent remedy. 

Internally aspirin should be given, as in catarrhal tonsillitis, 
followed during convalescence by the tincture of the chloride 
of iron. 

I^ Tinct. ferri chloridi 3i 
Glycerine 3iii 

Aquae destillat. q. s. ad ^ii. — ^jM. 
Sig. One teaspooiiful every three hours, diluted. 

Rest in bed and isolation are positive indications and should 
be insisted upon. 

Cold compresses, or the opposite, hot applications may give 
great relief. 

Chronically Enlarged Tonsils rec[uire surgical intervention. 
Whenever several distinct attacks of tonsillitis have occurred 
in a child, leading in the interim much enlarged tonsils, or when 
associated Avitli aural complications as progressive deafness, 
catarrhal and suppurative otitis media, or persistent enlargement 
of the glands of the neck, they should be removed, as they are 
a constant menace to the child from infections of many kinds. 

Symptoms. — Adenoids are usually associated with chronic- 
tonsillar hypertrophy and the symptoms are more or less the 
same. There is a facial expression peculiar to this condition; 
disturbance of the speaking voice; mouth breathing: disturbed 
sleep; snoring; and frequent attacks of acute tonsillitis. 

In a young child, the tonsils should be removed under a gen- 
eral anesthetic, gas, ether or chloroform. The operation is not 
as easily done under a general anesthetic as Avithout, but the 
inconvenience to the operator is more than counterbalanced by 
the comfort of the patient. It is brutal to forcibh^ hold a child 



162 THE DISEASES OF CHILDREN. 

and remove first one tonsil and then the other, and the shock 
to the nervous system is one which is recovered from only after 
a great while. I appreciate that this opinion is at variance 
with the ideas of many specialists, yet I am convinced this is cor- 
rect. The tonsils should not be removed too soon after an acute 
attack of tonsillitis, as the danger of postoperative hemorrhage 
is too great. There have been a number of deaths from hem- 
orrhage after tonsillotomy, and this danger should always be 
borne in mind. 

Tonsillotomy. — The instrument is chosen with the aperture 
of the proper size to allow the tonsil to easily slip through, slight 
pressure is made externally and being assured nothing but the 
tonsil is embraced in the instrument, pressure and traction are 
made by the thumb and fingers and the instrument with tonsil 




Fig. 42. — Tonsillotome. 

impaled upon the prongs, is removed. The same or a fresh 
instrument may be used for the opposite tonsil, but the second 
should not be removed until the bleeding has been stopped by 
pressure with a hemostat holding a small gauze sponge. 

Tonsillectomy. — Complete enucleation of the tonsil, has, in the 
hands of most operators completely supplanted the old method 
of tonsillotomy. The instruments needed are a tongue depressor, 
or a needle threaded with silk fifteen inches in length which is 
put through the end of the tongue at the frenum for the purpose 
of making traction and doing away with need for a tongue de- 
pressor; a tonsil knife for freeing tonsil from faucial pillars; 
volsellum forceps, and two snares, armed with silver wire. The 
patient, under a general anesthetic, lies upon its back, with right 
shoulder elevated by sand bag and head turned to operator sit- 
ting on its left side. The tonsil is grasped by the volsellum, the 
mucous membrane incised, and the tonsil freed of its lateral at- 



DISEASES OF THE NOSE, THROAT AND LARYNX. 163 

tacliments. The snare is then slipped over it and the entire 
tonsil enucleated with its capsule. While pressure is being 
used with forceps and sponge to allay hemorrhage more anesthetic 
is administered for the removal of the second tonsil. The second 
or upper tonsil is treated in the same manner, hemorrhage 
stopped, and the adenoid then removed. The patient is then 
turned over, head well over the edge of the table, and cold cloths 
applied to throat and forehead. A whitish deposit forms over 
the base of the tonsil which greatly resembles a pseudo-mem- 
brane, and without knowing what had been done, one might easily 
be led into a mistaken diagnosis of diphtheria. This disappears 
in four or five days. 

UVULITIS. 

An elongated uvula is sometimes seen in older children, rarely 
in infants. 

Symptoms. — There is an irritation in the throat, a hacking 
cough, especially when the patient is recumbent, and a constant 
desire to swallow. There may be pain on swallowing. The 
cough may be suggestive of bronchitis, but no signs are found 
in the chest, unless there is an associated bronchitis. 

Treatment. — The application once or twice daily of an astring- 
ent solution will usually suffice. The following is recommended : 

IJ Acidi tannici 3ss 

Glycerin! 3ii 

Listerine ^ii 

Aquae dest. q. s. ad. Jiii 
M. et ft. sol. 
Sig. Apply on cotton swab to uvula. 

In older children a gargle of Dobell's solution is beneficial. 
If the condition is chronic and does not respond to local appli- 
cations, an excision of the tip of the uvula may be necessary. 
Care should be taken to limit the excised portion to the tip of 
the mucous membrane, not cutting the muscle, in which event the 
pain following is very severe. 

Cold applied by eating ice, and cold cloths externally is of 
great benefit in relieving the pain following the operation. 



164 THE DISEASES OF CHILDREN. 

PERITONSILLAR ABSCESS. 

Synonym. — Quinsy. 

Etiology. — An infection from a tonsillitis or diphtheria is 
usually the cause. This affection is very rare at the extremes 
of life. 

Symptoms. — Pain in the throat, inability to swallow without 
its being greatly exaggerated and a peculiar voice, as if it were 
full of hot mush, are the principal symptoms. Stiffness of the 
neck, pain on opening the mouth, and pain referred to the ear. 
There is also an increased flow of saliva, which is swallowed 
with difficulty. An examination shows a very edematous area 
near the tonsil, which usually is very glassy in appearance. The 
uvula is pushed to one side by the accumulations of pus from 
behind. 

Prognosis. — A few cases have been known to rupture during 
sleep, pus entering the larynx, producing death by strangulation. 
Edema of the larynx may follow also. 

Treatment. — The accumulation may be quite tense and require 
but a very superficial incision to evacuate the pus. The posi- 
tion of the ascending pharyngeal artery must be remembered in 
making the incision. In others the pus is difficult to locate as 
it constantly burrows behind the fascia but finally toward the 
surface and may rupture spontaneously. Relief is almost imme- 
diate as soon as the abscess is drained. 

Hot applications and hot gargles assist materially in reducing 
pain and hastening rupture. 

RETROPHARYNGEAL ABSCESS. 

The retropharyngeal nodes become infected by bacteria through 
the medium of the lymphatics, in tonsillitis, measles and other 
septic conditions. It may be due to vertebral caries, and as a 
complication of tuberculosis, rickets and syphilis. 

It occurs comparatively frequently in infancy and childhood, 
especially during the first year. 

Symptoms. — The acute symptoms, pain and obstruction to 
swallowing, may begin abruptly. The glands at the angle of the 
jaw are swollen and tender. The usual examination of the 



DISEASES OP THE NOSE, THROAT AND LARYNX. 165 

throat may reveal the cause of the trouble at first glance, and 
the finger introduced in the mouth will feel the doughy tumor 
extending beyond the reach of the finger. Hoarseness is pres- 
ent if the abscess presses down upon the larynx. 

Treatment. — The positive indication is to open the abscess and 
evacuate the pus through an opening as large as possible. 

I have seen one infant of four months in which the first exami- 
nation by the finger caused dj^spnea, necessitating intubation. 

ADENOIDS. 

Pathology. — An hypertrophy of the lymphoid tissue or the 
mucous glandular tissue in the nasopharynx or vault of the 
pharynx is designated as an adenoid growth. The growth may 
be lobulated and attached by one base, or there may be more 
than one of these masses. The mass when removed may resem- 
ble a bunch of grapes in its conformation. 

Owing to the passive congestion of the nasopharyngeal mucous 
membrane from pressure and mechanical irritation of the growth 
there is a constant secretion of mucus, escaping through the 
nares and into the throat. 

Bacterial growth in the nasopharynx in Avhich ithere are 
adenoids is very active, the pneumococci, streptococci and staph- 
ylococci being most often found. 

The mucous membrane around the opening into the Eu- 
stachian tube, and extending up the tube, is congested and 
swollen, and bacteria are present. 

The frequency of adenoids has been given as from 15 to 50 
per cent of all children. 

Etiology. — It is often a family characteristic. Rachitis, bad 
hygienic surroundings, chronically enlarged faucial tonsils, 
thumb sucking, indiscretions of diet, especially liberal eating of 
sweets, are among the causes of this condition. 

Symptoms. — A child with adenoids usually presents a train 
of symptoms which are fairly characteristic. It is more than 
usually susceptible to ''colds," having tlie snufHes and a con- 
stant nasal discliargo; breathes tlirougli tlie nioutli, botli ash^e]) 
and awake, but especially when asleep and lying upon its back; 
it is inattentive from deafness, and apathetic, due to impoverished 



166 THE DISEASES OF CHILDREN. 

blood from respiratory obstruction ; complains frequently of ear- 
ache. 

After adenoids have existed some time the change which 
takes place in the conformation of the face is fairly character- 
istic. Guye has designated this facies as aprosexia. There is a 
peculiar prominence of the nasal bones, giving a tendency to 
an appearance called hatchet face, the lips are partially open 
to permit of mouth-breathing, as it is impossible for a free ex- 
change of air to take place through the nose. 

It has been generally believed that adenoids were peculiar 
to children beyond the age of two years, but it has been found 
by a number of observers that they occur in early infancy, the 
earlier they occur the more serious the after-effects, unless early 
remedied. There is a greater tendency to recurrence of the 
growth after removal in the very young. 

Giving to the low position of the nasopharynx in infancy and 
its relatively greater length from before backward, and the small- 
ness of the nose and its cavities, a very small growth causes 
greater obstruction. The presence of adenoids in an infant in- 
terferes with its nasal respiration to such an extent that sucking 
and swallowing are much interfered with, and these in- 
terferences with nutrition, and insufficient oxygen, cause a 
condition of malnutrition which is oftentimes very serious. All 
of the diseases of malnutrition, especially rickets, are apt to fol- 
low, deformities of the chest, the so-called pigeon breast, is 
frequently seen. It is often necessary to differentiate adenoids 
in which there is a constant "snuffles" from congenital 
syphilis. Infants so affected are restless at night, waking fre- 
quently, and this interference with proper rest adds greatly to 
the state of malnutrition. The following application may be 
made to the adenoid-bearing area, but without much hope of 
causing absorption. 

IJ Tinct. iodini 5ss 

Menthol gr. ss 

Benzoinated albolene ^i. 
M. Sig. Five drops in anterior nares with child lying on back. 

In later childhood it is rare to find a case presenting adenoids 
that does not also show considerable enlargement of the faucial 



DISEASES OF THE NOSE, THROAT AND LARYNX. 167 

tonsils, and it is a fact frequently recognized that if the adenoids 
are removed and the faucial tonsils left the tendency to the re- 
currence of adenoids is very great. 

Owing to the tendency to rapid propagation of pathogenic 
bacteria in the nasopharynx in which there are adenoids the 
complication of infection of the middle ear is very frequently 
observed. The nasopharynx is filled by the growth which presses 
on the opening of the Eustachian tube; this interferes with the 
air in the middle ear and deafness, which is a prominent feature 
of these cases, is caused. 

Treatment. — There is but one treatment for adenoid growth 
and that is surgical. A number of observers have tried the 
effect of local application of absorbofacients and internal admin- 
istration of the iodides with no effect whatever. There is per- 
haps no operation that in itself is so simple, which gives rise to 
such excellent and prompt results, as the cleaning out of the 
nasopharynx of an adenoid growth sufficient in size to give 
symptoms. 

In infants the removal can frequently be accomplished with- 
out the use of instruments, as the mass of tissue is so soft as to 
make it possible to crush it and remove it by the finger. 

In older children it is my opinion that the operation should 
never be done without a general anesthetic. The dangers of 
the anesthetic are greatly outweighed by the shock to the nerv- 
ous system, from forcibly holding the patient and brutally 
scraping out this growth. Cases in which this operation is 
done without an anesthetic are much more apt to have the 
growth recur from the incompleteness of the operation. In com- 
petent hands the best anesthetic is chloroform. I make this 
statement in spite of the statistics showing the comparative 
greater safety of ether over chloroform. I have given chloro- 
form for this operation a great number of times without ever 
seeing a dangerous symptom. The patient should be recumbent 
upon the table upon which the operation is to be done, and the 
anesthesia produced should be only to the primary degree. The 
mouth gag of the O'Dwyer intubation set is then introduced, 
the head brought well to the edge of the table and below the 
level of the body, the face turned to one side. The hair is pro- 



168 THE DISEASES OF CHILDREN. 

tected from soiling with the blood by a rubber bath cap which 
fits snugly over the forehead and under the occiput. With the 
patient anesthetized only to the primary stage there are still some 
reflexes present, and the tendency to swallow blood is much less 
than if they are completely under the anesthetic. There are few 
operations in which the loss of blood is as great for the amount 
of work done, and for this reason it is always well for members 
of the family not to be present during the operation. 

The child lying upon its back, the shoulders are pulled to 
the edge of the table, the head lowered, with the face turned 
to the side, the mouth held open with the gag and the finger 
as a guide, the growth is removed by means of the curette, which 
ordinarily will remove the entire mass in one or two scrapings. 
The roof of the pharynx must be carefully investigated with the 
finger to ascertain if entirely clean. The danger of secondary 
hemorrhage is very slight, although a few cases have been re- 
corded of this nature. After cleansing the face the child is put 
to bed with head flat, and the family warned of the possibility 
of its vomiting blood which may have been swallowed during 
the operation. If there is no nausea following, in the course of 
an hour or so, crushed ice may be given the patient if it craves 
water, and later ice cream or cold milk when nourishment is 
necessary. 

As a rule no after treatment is needed, and the beneficial ef- 
fects of the operation while generally not immediate are very 
soon noticed in the relief of all previous disagreeable symptoms, 
the first usually to disappear is the snuffles or symptoms of cold 
in the head. There is a change in the voice and the child is less 
restless at night, and the mouth-breathing soon disappears. In 
those who have been in the habit of breathing through the mouth 
for some time it may be necessary to frequently remind them 
of the necessity of keeping the mouth closed. 

DISEASES OF THE LARYNX. 

Acute Catarrhal Laryngitis. 
Synonyms. — Croup. Spasmodic croup. Catarrhal croup. 
Etiology. — Exposure to cold is the most frequent predisposing 
cause. Any of the bacteria found in the throat in tonsillitis 



DISEASES OF THE NOSE, THROAT AND LARYNX. 169 

may be the active cause of the inflammation. The bacillus of 
diphtheria is not present, as a membrane would be the result of 
such invasion and a true croup caused. 

Symptoms. — The child is usually put to bed in apparently a 
normal condition. It may perhaps have had a slight hoarseness 
or a hacking cough during the day or several days previously, 
or a slight coryza without the cough. After having been asleep 
for some time it will cough, the sound produced being harsh and 
brassy which is the characteristic croupy cough, and which 
strikes terror to every mother's heart. This cough may awaken 
the child, and there is a rasping character to the inspiration 
and the cry, which may be heard and recognized some distance 
away. If very severe the child may show considerable pallor 
and exhibit other symptoms of dyspnea, clutching at the throat 
with a recession of the supraclavicular and infraclavicular spaces 
with each inspiration. The skin is clammy as a rule, though 
there may be a dusky flush to the cheeks if there is any fever, 
which is usually below 103° F. 

The spasmodic stage may last some hours, but it is usually 
shorter in duration, and by morning the child is asleep and 
breathing quietly. During the day it will play around with- 
out, as a rule, much hoarseness evidencing itself. The croupy 
cough, however, usually recurs the following night or for several 
nights, however, less severe as a rule. 

Diagnosis. — This must be made from laryngeal diphtheria. In 
this the symptoms grow gradually worse, instead of disappearing 
during the day, to recur at night, as in catarrhal laryngitis. 
Some membrane is usually present in other parts of the throat, 
in diphtheria. 

In laryngismus stridulus, the pronounced croupy cough is not 
so prominent, the dyspnea and stridor being most marked. 
There is no fever in laryngismus and the duration is shorter. 
Laryngismus is a prominent symptom of rickets, and does not 
occur in other conditions. 

Prognosis. — This is good when uncomplicated. 

Treatment. — If the stridor is great, the ])ost results can be 
had by giving a preliminary dose of syrup of ipecac of 20 to 
60 drops, for its full effect upon the stomach. After vomit- 



170 



THE DISEASES OF CHILDREN. 



ing, the whole aspect of the case is usually changed, as by doing 
so the mucus in the trachea and larynx is dislodged and this 
mechanical obstruction removed. This dose can be repeated at 
half hour or hourly intervals as needed to produce emesis. Con- 
tinuing the effect of relaxation, 
good results are had from anti- 
mony and ipecac, 1/100 grain 
each, every hour. 

Excellent results are had from 
allowing the child to breathe 
I steam, and the ''croup kettle" 

which generates steam by the bed- 
side, should be used. One tea- 
spoonful of the tincture of benzoin 
to a pint of water vaporized is of 
great service. "When the child is 
asleep a sheet tent should be 
erected over the crib so as to con- 
fine the steam. The kettle, as long 
as the lamp is lighted, should be closely watched and not left 
unattended at all. 

For severe cases, with great recession of the spaces, and ap- 
parent danger of complete obstruction, intubation, as for diph- 
theritic laryngitis, should be performed. 

The application of a wet, cold compress is of service in reduc- 
ing the swelling of the vocal cords. 




I 



g. 43. — Croup Kettle. 



Congenital Laryngeal Stridor. 

This is an obscure condition and no cause has been satisfactor- 
ily named, in the absence of pathological conditions which by 
pressure would cause obstruction to the larynx. Enlarged thy- 
mus gland has been found, causing pressure, the peculiar crow- 
ing sound being produced. 

Symptoms. — Within a few days after birth the child is no- 
ticed to make a peculiar high-pitched crowing inspiratory sound ; 
louder when disturbed or crying, and then associated with re- 
cession of the supra and infra clavicular spaces. The proper 



DISEASES OF THE NOSE, THROAT AND LARYNX. 171 

oxygenation of the blood appears to occur as no cyanosis is pres- 
ent. 

Course. — The condition tends to a spontaneous cure, a decided 
improvement usually occurring before the end of the first year. 
No treatment is of avail. 



CHAPTER IX. 

DISEASES OF THE EAR. 

Deafness in children is much more frequently present than 
is ordinarily thought, and in school children may prove a serious 
handicap to their progress. In this period any defect in hear- 
ing will interfere with the development of speech, and inatten- 
tion and slow mental development is the result. Inattention 
in an otherwise normal child should cause an examination to 
be made of the child. 

Adenoids is perhaps the most frequent cause of deafness ; next 
being nasopharyngeal catarrh, with an occlusion of the 
Eustachian tube and the extension of the inflammatory process 
to the middle ear. These children if watched at play will be 
seen to have less endurance, and this is exaggerated in damp, 
humid weather. 

Every child should be examined at school for acuteness of its 
hearing, and in the presence of its teacher. If the hearing is 
found defective, an otologist should be consulted in order to 
locate the cause of the defect. 

This is one of the many advantages which can be gained from 
medical inspection of schools. 

EXTERNAL AUDITORY CANAL. 

Furunculosis. — The most frequent condition affecting the ca- 
nal is a furunculosis of the skin inside the meatus. This is not 
often seen in young children but comparatively often in those 
approaching puberty. 

Etiology. — The practice of children putting foreign bodies in 
their cars is a potent factor. This causes an abrasion of the 
skin and an infection, usually by the staphylococcus, which in 
one form or another are normally found in the hair follicles 

172 ^ 



DISEASES OF THE EAR. 173 

of the canal. In older children the employment of pin heads 
and sharp instruments to give relief from itching or to clean 
out the normal secretion of wax results in an infection. 

Pathology. — There may be a diffuse inflammation of the skin 
of the entire canal, or one or more discreet furuncles. The 
swelling may be diffuse enough to make an examination of the 
drum impossible. 

Symptoms. — Perhaps more pain is caused by inflammation lo- 
cated here than at any other part of the body, owing to the tense- 
ness of the tissues of the canal. Pressure pain develops early, 
and if the furuncle is located near to the meatus movement of 
or touching the external ear causes pain. There may be a slight 
rise of temperature, to 101° F., occasionally, loss of sleep and 
of appetite, with general depression and irritability. Unless re- 
lieved by incision, the furuncle generally ruptures spontaneously 
during the first week and immediate relief is afforded by the 
escape of pus and blood. Unfortunately one boil may be followed 
by another, as it is next to impossible to keep the parts sterile 
after discharge of pus from the first one takes place. 

The location of the boil can be made out by the use of a 
cotton-protected probe. A speculum cannot always be used on 
account of the tenderness. Mastoiditis must be differentiated 
from, which is chiefly done by pressure on the mastoid bone, 
eliciting tenderness in the latter only. 

Treatment. — Abortion of the boil is possible. This can some- 
times be effected by leeches applied just external to the auditory 
canal, care being taken to plug the canal with cotton to prevent 
their migration into it. Locally, cotton, saturated with a 50 
per cent ichthyol and glycerine solution may be of benefit. The 
continuous application of heat by irrigation with a fountain 
syringe is of great benefit. Efforts at aborting the boil being 
ineffectual, an incision is absolutely necessary, and this should 
be made with a special furuncle knife with a triangular or a 
half -curved blade, and the incision made through the furuncle 
and the tissue on either side of it, thus draining the collection 
of pus and reducing the congestion also. 

This operation is so painful that the administration of a gen- 
eral anesthetic is urged. Laughing gas is most efficient, having 



174 THE DISEASES OP CHILDREN. 

the advantage of lack of after-effects, nausea, etc. If this is not 
available, chloroform to the primary stage should be used. 

If these furuncles are recurrent the injection of the bacterial 
vaccines is recommended. 

Local antiseptics and cleansing should constitute the after 
treatment, probably using irrigations two or three times a day. 

IMPACTED WAX. 

The natural secretion of cerumen may be increased in amount 
and collect in the canal, and v^hen mixed v^ith the epithelium 
of the canal may obstruct the entire meatus. The mass may be 
pushed inward and press against the drum. This frequently 
causes symptoms such as tinnitus, gradual deafness, a sense of 
fulness in the ear, or more or less pain, dizziness and perhaps 
vomiting. An examination of the ear with a good, reflected light 
is sufficient to make the diagnosis. At first it may resemble a 
foreign body in the canal. 

Treatment. — The wax may be removed with a curette if close 
to the orifice, but frequently will have to be softened by repeated 
syringing with warm water in a piston syringe. The force 
obtained from a fountain syringe will not disintegrate the mass 
as a rule. The fluid used should either be plain sterile water, 
normal salt solution or saturated boracic acid solution. 

If syringing does not succeed in disintegrating the mass, a 
solution can be used as follows for instilling into the ear three 
times a day, until the wax has softened : 

I^ Acid carbolic ITt-i 

Acid boracic gr. xx 

Sodium biborat. gr. x «> 

Glycerine ^ss 

Aquae dest. ^^s 

A dry dressing of powder should be blown in the ear after 
the wax has been removed. 

THE MIDDLE EAR. 

The student and practitioner should familiarize himself with 
the appearance of the normal drum membrane, should be able 



DISEASES OF THE EAR. 175 

to locate the landmarks, as follows: The short process of the 
hammer; the handle of the hammer or malleus; the triangular 
light spot. The normal color is a pearl-gray, and abnormal con- 
ditions evidence themselves chiefly in a change of color of the 
drum. 

Inflammations of the middle ear are either suppurative, which 
may or may not have been the result directly of an extension 
upward of an inflammation of the Eustachian tube. 

ACUTE TUBOTYMPANIC CATARRH. 

Etiology. — ^Whether the normal middle ear contains bacteria 
is a debatable question, equally prominent authorities holding 
opposite views. Bacteria may gain entrance to the tympanic 
cavity through an opening in the drum, the result of trauma, or 
through the Eustachian tube. They may obtain entrance also 
via the blood and lymphatics. 

The most frequently observed bacteria are the streptococcus 
and staphylococcus; though the following may be found, the 
pneumococcus, the bacillus pyocyaneus, Klebs-Loeffler bacillus, 
the meningococcus intracellularis, influenza bacillus and the colon 
bacillus. 

Nasopharyngeal adenoids are one of the most frequent causes 
of catarrhal inflammation of the mucous membrane of the middle 
ear. They are the most frequent cause of the so-called colds 
and acute coryza which so frequently precede an acute tym- 
panic catarrh without suppuration. 

Pathology. — Inflammation may rarely be limited to the Eu- 
stachian tube, but usually extends to the cavity as well. As a 
result of the inflammation, swelling and occlusion of the Eu- 
stachian tube there is a slight accumulation of serum and an 
absorption of the air in the middle ear, and a coincident inward 
depression of the drum membrane. 

Symptoms. — The first symptom which is present is usually an 
impairment of hearing, followed by a sense of fulness on the 
affected side, ringing in the ear, perhaps dizziness. "When the 
catarrhal inflammation extends to the middle ear there is a 
swelling of the mucous membrane and more or less pain. 

In the early stages, when most of the involvement is in the 



176 THE DISEASES OF CHILDREN. 

Eustachian tube, the drum membrane is retracted, but subse- 
quent examinations may show a collection of fluid in the cavity. 

Prognosis. — Early recognition and prompt treatment make 
the prognosis favorable. The restoration of a diseased condi- 
tion of the nasopharynx to normal greatly influences the prog- 
nosis and limits the possibilities of a return of the condition. 

Treatment. — When only the tube is involved, with more or 
less occlusion, it must be opened, either by the Eustachian cathe- 
ter or by the Politzer bag. The catheter is entirely impractical 
in children, and inflation of the drum by the Politzer bag yields 
the best results. 

First cleanse the nose and pharynx with an antiseptic spray 
(Dobell's solution or Seiler's solution), followed by a nebulizer. 

Several methods of Politzeration are advised. The child is 
seated, the tip of the bag is placed well in the nostril of the 
affected side and held, the opposite nostril being compressed. 
The child is then told to count one, two, three, and as the last 
word is said the bag is squeezed, which usually effectually in- 
flates the affected side. The child may be told to fill the lungs 
with air and forcibly to blow it out through puckered lips, the 
bag is then squeezed and the drum inflated. In older children 




Fig. 44. — For paracentesis of the drum. 

the inflation can be accomplished as a swallow of water is taken, 
but in younger children this is impractical because of the danger 
of choking. 

The Politzeration should be done every day for three or four 
days, and then every other day, and finally once a week for 
several weeks. 

In the presence of a collection of fluid in the cavity a para- 
centesis or incision of the drum should be done. 

For this operation a general anesthetic should always be given 
as the pain is very acute. The necessity for a paracentesis rarely 



DISEASES OF THE EAR. 177 

exists until the patient has already suffered acutely for a num- 
ber of hours, probably having lost much sleep; hence the inflic- 
tion of additional acute pain should not be allowed. Local 
anesthetics are not of much avail. The following can be used 
with some benefit: 

IJ Cocaine muriat gr. x 
Ac. boracic saturated sol. 
Alcohol a a 5i 

M. Politzeration sliould be performed after paracentesis. 

ACUTE CATARRHAL OTITIS MEDIA. 

Pathology. — The mucous membrane lining the middle ear is 
acutely inflamed and swollen, and an exudate usually occurs, 
being either serous or mucous, bathing the mucous membrane. 
There may be an accumulation sufficient to fill the cavity. 

Etiology. — ^While this condition may occur as a primary af- 
fection it is usually an extension of the process from the naso- 
pharynx, any of the bacteria named in the previous section being 
found in the tympanic cavity. Bacteria in the nasopharynx 
may be forced in the cavity through the tube by nasal douches 
or sprays, gargling or coughing when swallowing. 

As a complication in the acute exanthemata, this form of otitis 
is most frequent. 

Symptoms. — Any severe pain in the ear is always suggestive 
of this form of trouble. It is at first a dull, deep-seated ache, 
gradually increasing in severity until it becomes sharp and lan- 
cinating; sleep is impossible, and older children walk the floor 
holding the affected side. Remissions in the severe pain are 
hardly long enough to allow the child to fall asleep, crying out 
with each exacerbation. Younger children usually pull at the 
affected side. 

If old enough to tell, the watch test evidences deafness to a 
greater or less degree, according to the severity of the inflanuna- 
tion and amount of effusion. Some complain of the ringing in 
the ears, in others this is less noticeable. 

Pain is severe until the fluid in the ear escapes, either through 
a spontaneous rupture in the drum or a paracentesis of the drum 



178 THE DISEASES OF CHILDREN. 

is performed, when the feeling of relief is immediate and the 
child falls asleep. 

In children there is usually a rise of temperature, from 1° to 
3° F., though there may be no rise at all. As a complication 
of the exanthemata there is nearly always an elevation. A child 
may waken in the night with an earache, having previously suf- 
fered from an acute coryza, perhaps have a slight remission in 
the pain during the day, with a recurrence of it at night, per- 
manent relief being had only after spontaneous rupture of the 
drum and escape of the mucus or serum, and all of this without 
elevation of temperature. This rupture may occur in 12 hours 
after the onset of the pain, but may be delayed for three days. 

The drum membrane, if examined before rupture, is found 
to have changed to a deep or cherry-red color, the landmarks 
have disappeared, and if the exudation has occurred in the cavity 
the drum bulges outward in some portion, usually it being great- 
est in the upper, posterior portion. If the drum has previously 
ruptured the canal is filled with exudate, and a free view of the 
drum cannot be had without a previous cleansing with a cotton- 
protected swab. 

Untreated or neglected cases of the catarrhal variety of otitis 
usually develop into the suppurative form, especially after a 
perforation of the drum has occurred. The opening in the drum 
from a perforation is usually found in the inferior quadrant, to 
the right or left. 

Prognosis. — The majority of these cases completely recover. 
The condition of the nasopharynx influences the prognosis. Per- 
sistence of a nasopharyngeal catarrh, adenoids and anemia, tend 
to the likelihood of recurrence of this trouble. 

Treatment. — If seen early, before there has been a perfora- 
tion of the drum, an anodyne is necessary, opium in some form 
being most efficacious. The camphorated tincture or the deodor- 
ized tincture may be used. 

The tampon in the canal, suggested by Barnhill, is of service 
also. A cone of cotton is twisted on the end of an applicator, 
saturating the end of the cotton with a phenol (10 per cent) and 
glycerine (90 per cent) solution, and holding it over a flame 
until as hot as can be stood on the back of the hand, and before 



DISEASES OF THE EAR. 179 

it has had time enough to cool it is removed from the applicator 
and carried back against the drum membrane with the end pro- 
jecting from the meatus. 

I have found excellent results follow the use of an irrigation 
of the ear with a fountain syringe, using water as hot as could 
be borne and holding the syringe not more than 12 inches above 
the head, thus doing away with the pressure against the drum. 
The child should be persuaded to put his hand in the water for 
a moment to become familiar with its temperature before it is 
used in the ear. 

Usually before the physician has been called the mother has 
dropped into the ear some warm sweet oil and laudanum which, 
as long as it retains its heat, is effectual, but little absorption of 
the laudanum occurring. 

Paracentesis of the drum should be performed as soon as a 
bulging drum has been found. This should be done under strict 
antiseptic precautions and in the subsequent treatment being 
most careful to prevent infection. Rest in bed, if fever is pres- 
ent; indoors, if the child is up. 

An occasional dose of calomel, 1 grain at a dose at bedtime, 
followed by a saline the next morning ; syringing the discharging 
ear frequently; at first, every two or three hours, daily after 
this ; drying of the canal by cotton swabs and insufflation of 
canal with boracic acid powder constitute the treatment which 
generally yields the best results. 

A sudden cessation of the discharge, an increase in or return 
of pain, rise in temperature, usually indicates a too early closure 
of the drum. 

ACUTE SUPPURATIVE OTITIS MEDIA. 

This form may follow the catarrhal otitis or originate as the 
suppurative form. A large percentage of Cases of deafness are 
due to this variety of inflammation, and chronic otitis is a fre- 
quent ending. 

Etiology. — One of the most frequent causes is bacterial inva- 
sion of the tympanic cavity as a complication of influenza. Large 
numbers of acute-discharging ears are seen every winter in which 
influenza is epidemic. 



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DISEASES OF THE EAR. 181 

The exanthemata, especially scarlatina and diphtheria, are 
frequently complicated by suppurating middle ears. In the 
former disease infection of the ear most frequently follows the 
membranous form of angina. The streptococci are most fre- 
quently found as the infecting organism. 

As in the other varieties of middle ear involvement, the pres- 
ence of adenoids is an exciting factor of middle-ear suppuration. 

Symptoms. — No other condition of the ear presents such a 
variety of symptoms as this. Some may be present with severe 
constitutional and local symptoms, as a temperature ranging 
from normal to 103° or 104° F., severe prostration, deafness and 
agonizing pain in the ear. In others one of the first symptoms 
will be the discharge from the ear following, perhaps, a sense of 
discomfort or fulness in the affected side. 

It is usual, however, for the trouble to be ushered in with se- 
vere pain, deafness, tinnitus, perhaps vertigo or dizziness. 

The accompanying chart is of a patient three years of age 
who presented but few symptoms before the discharge began, 
and practically none afterward, except the temperature, loss of 
appetite and some loss in weight. The discharge was profuse, 
and when the opening in the drum became slightly closed, caus- 
ing retention of secretions, all of the symptoms were aggravated. 

"When occurring as a complication in the exanthemata there 
is usually a rise in the temperature, especially if the suppura- 
tion occurs late in the course of the disease, as may be the case. 

Usually with the rupture of the drum the pain subsides imme- 
diately, and the child is free from pain unless the opening 
becomes blocked with discharge, when pain is again severe. 
Where the child has been previously restless and crying, as soon 
as the rupture takes place it falls into a peaceful sleep. It is 
astonishing to see the amount of discharge which may come from 
the middle ear. It is usually thick and yellow, caking in flakes 
upon the ear and beneath when it is profuse enough to run over. 

It is impossible to state the character of the secretion in the 
middle ear by the looks of the drum membrane, though in the 
suppurative form there is apt to be a larger amount, hence more 
bulging. The membrane is reddened, more or less uniformly, 



182 THE DISEASES OF CHILDREN. 

except at the site of the rupture, which may be imminent, this 
showing signs of necrosis by change in color. 

The opening in the drum as a result of a spontaneous rupture 
may vary from a slit to a practical washing away of the entire 
drum. 

The tendency in the former variety of opening is to too readily 
heal, closing before the discharge has ceased. 

Prognosis. — The earlier this condition is recognized and 
properly treated the better the chances of recovery with normal 
hearing. Continuance of fever and other symptoms after dis- 
charge has begun indicates an involvement of deeper structures 
as the mastoid and the brain. 

Untreated cases develop into a chronic condition with con- 
tinuous discharge, washing away of the entire drum, frequently 
evacuation of the ossicles and permanent deafness. 

Treatment. — The indications for treatment as soon as diag- 
nosis is established are very clear ; prompt and efficient drainage 
should be established as early as possible, and maintained, and 
extension of the inflammatory process stopped if possible. 

The local application of heat, continuous irrigation with hot 
saline solution for 10 or 15 minutes, or perhaps the administra- 
tion of an anodyne may be needed for the relief of the pain. 
In some cases leeches can be employed with advantage, but 
the child should not be allowed to see them or told what is 
being done when they are applied. As soon as a bulging of the 
drum has been diagnosed a free incision should be made, and, 
as suggested in the previous section, this should not be done 
except under a general anesthetic. It is a most painful opera- 
tion ; a view of the drum cannot be satisfactorily obtained with- 
out it, and if done without, and great pain caused, the child 
will be intolerant of examination and treatment for years after- 
ward. Early evacuation of the pus by paracentesis limits the 
chances of extension of the process to deeper structures from 
pressure of the pent-up secretion. 

Frequent examination of the drum should be made after para- 
centesis to note the changes occurring in the drum, the tendency 
of the opening to close, etc. 

The patient should be confined to bed during the active stage 



DISEASES OF THE EAR. 



183 



of inflammation. The child should have a pledget of cotton in 
the external auditory canal and a pad of gauze covering the 
entire external ear, this confined by a bandage over the head. 

Lying with the affected side down is a great aid in drainage. 
Frequent irrigation is of great benefit, at least every three hours 
at first. 

The following table given by Barnhill gives excellently the 
differential diagnosis of the three forms of trouble just 
described : 



DIFFERENT DIAGNOSIS OF ACUTE TUBOTYMPANIC CATARRH, ACUTE CATARRHAL 
OTITIS MEDIA, AND ACUTE SUPPURATIVE OTITIS MEDIA. 



Acute Tuhotympanic 
Catarrh. 



Acute Catarrhal Otitis 
Media. 



Acute Suppurative 
Otitis Media. 



Absent in the ear; usu- 
ally amounts only to 
a sense of soreness in 
throat, as of foreign 
body. More or less 
pain along course of 
Eustachian tube. 

Absent, unless the tuho- 
tympanic catarrh is 
secondary to some 
other ailment as a 
mild form of measles, 
which primary dis- 
ease gives rise to the 
fever. 

Moderate. Patient com- 
plains of great deaf- 
ness, however, largely 
because of the sud- 
denness of onset. 



PAIN. 

Severe in depths of the 
ear, radiating over 
side of head. Worse 
on lying down. Pain 
increased by blowing 
nose or coughing. 

FEVER. 

Temperature usually 
elevated, 100° F. in 
infants and young 
children. 



DEAFNESS. 

Very considerable in af- 
fected ear. 



Very severe, of lanci- 
nating, tearing va- 
riety. Increased by 
recumbent position, 
by coughing, sneez- 
ing, blowing of the 
nose, etc. 

Ranges from 102 to 
104° F., the height of 
temperature depend- 
ing much upon the 
presence of some 
general disease, as 
measles, scarlet fever 
or la grippe. 

Very great in affected 
ear. Patient very 
deaf when both ears 
are involved. 



Kone. 



PROSTRATION OF PATIENT. 

Usually moderate . 



Sometimes 
able. 



consider- 



Often very great. 



184 



THE DISEASES OF CHILDREN. 



Present and often se- 
vere. 



Greatly retracted in 
first stage, less so in 
second stage. In- 
flammation absent, 
vessels along handle 
of malleus sometimes 
injected. After ex- 
udation into the 
tympanic cavity has 
occurred, a dark, or 
sometimes a light 
line may be seen 
crossing membrane, 
and indicating level 
of fluid. All land- 
marks present. 

Drum membrane sel- 
dom ruptured. 



None except after para- 
centesis. 



Rarefied in first stage. 
In second stage fre- 
. quently contains a 
yellowish serum, or 
ropy, mucoid ex- 
udate, which is visi- 
ble through non-in- 
flamed membrana 
tympani. 



TINNITUS, VERTIGO, ETC. 

Head noises not a prom- 
inent symptom ex- 
cept in later stages, 
after, the pain and 
fever have subsided. 
Vertigo and nausea 
rare. 

DRUM MEMBRANE. 

Little or not at all re- 
tracted at onset, 
later is bulging over 
some quadrant. In- 
jected at first, and 
later a diffuse, uni- 
form redness covers 
whole membrane. 

Landmarks usually 
all obliterated with 
possible exception of 
short process of the 
malleus. 



PERFORATION. 

Drum membrane usu- 
ally perforated after 
from one to three 
days. 

DISCHARGE. 

Thin, seromucous dis- 
charge immediately 
after rupture or para- 
centesis. May later 
become purulent 

from infection. 

TYMPANIC CAVITY. 

Contains seromucous 
exudate, which bulges 
membrane, but is not 
visible through in- 
flamed membrane. 



If present in beginning 
are so masked by 
severe pain that they 
are not mentioned. 
Sometimes present 
during convalescence. 



Intensely reddened, es- 
pecially in upper por- 
tion ; swollen, bulg- 
ing, opaque. Land- 
marks all obliter- 
ated. Drum- mem- 
brane may be largely 
destroyed during first 
two or three days. 



Always present after 
two or three days. 



Sanguinopurulent at 
moment of perfora- 
tion, purulent later. 
Usually very pro- 
fuse. 



Contains pus. Mucous 
membrane greatly 
swollen, with ne- 
crotic areas in worst 
cases. Incus and 
hammer sometimes 
carious. 



DISEASES OF THE EAR. 



185 



Not painful. Immedi- 
ate and marked im- 
provement results to 
hearing. 



TYMPANIC INFLATION. 

Painful. Little or no 
improvement in hear- 
ing except in later 
stages. 



Painful and should sel- 
dom be performed 
during height of in- 
flammation. 



Usually accompanies or 
follows a cold in the 
head or a naso-phar- 
yngitis. May result 
from mild attacks of 
exanthemata or ton- 
sillitis. 

Never occurs. 



HISTORY. 

Accompanies or follows 
the exanthemata of 
moderate severity, 
and the acute tonsil- 
lar and naso-pharyn- 
geal inflammations. 

MASTOID COMPLICATION. 

Seldom occurs. 



Follows or accompanies 
the more violent 
forms of the ex- 
anthemata, la grippe, 
ulcerative tonsillitis, 
diphtheria, etc. 



Frequently occurs. 



MASTOIDITIS. 

The mastoid is but poorly developed in young infants, and 
fortunately not so very frequently involved as later in childhood. 

Etiology. — Probably less than 1 per cent of cases of mastoid- 
itis develop without being secondary to acute suppurative mid- 
dle-ear disease. Neglected cases of suppuration with long- 
retained pent-up secretion in the middle ear makes infection of 
the mastoid cells an easy matter. 

Diagnosis. — This is not always easy, and many factors influ- 
ence one in a diagnosis. It should be suspected in all cases of 
severe and prolonged suppurative, middle-ear cases. Constitu- 
tional symptoms are apt to be more severe upon the develop- 
ment of mastoiditis, temperature more elevated, pain more acute, 
with swelling and tenderness over the mastoid. 

Symptoms. — A previously free discharge may cease or become 
much lessened, the temperature usually rises quite high, 104° F. 
or 105° F., or there may be a very little rise, if any. 
The pain or discomfort and tenderness are quickly located behind 
the ear, which is shortly followed by a swelling of the skin just 
back of and slightly below the middle point of the back of the 
ear. "A sagging of the posterior superior meatal wall" has 
been suggested as a fairly constant occurrence. There is much 
restlessness and disturbed sleep. 



186 THE DISEASES OF CHILDREN. 

Prognosis. — This condition is an extremely serious one and 
causes great anxiety on the part of the physician or specialist 
in charge. The decision as to employment of surgery is difficult 
to make and requires keen observation and careful consultation. 
Possible meningeal involvement in children should always be 
borne in mind. 

Treatment. — Local application of cold over the affected mastoid 
by cloths, small ice bags or specially-devised ear ice bags is first 
indicated, or the opposite, heat, may be equally effective in re- 
ducing inflammation and easing pain. Sedatives may be posi- 
tively necessary but should be used with great caution and 
conservatism. Leeches to the affected side may be serviceable if 
applied early in the involvement. 

As before stated, just where the medical treatment fails and 
surgery is indicated is a fine line not easily differentiated, and 
a safe rule to follow, is when in doubt operate. 

A competent specialist should always be associated with the 
practitioner in these cases. 



CHAPTER X. 

DISEASES OF THE EYE. 

Eyestrain. — The prevalence of eyestrain in school children 
is but little appreciated by teachers, parents or physicians. The 
eyesight should be systematically tested in all school children 
by a medical examiner, and the parents of those found deficient 
notified and requested to have the defect corrected. 

Statistics of different observers ^ show from 30 to 50 per cent 
of several thousand school children, systematically examined, 
to have visual defects, who could use glasses for close work with 
benefit to their eyes. It was found an average of 11 per cent 
of school children wear glasses. Investigation in 20,000 cases 
showed that 7.3 per cent of all children suffer from 6/18 or 
worse defective vision. Of the various errors of refraction the 
following table shows the result in 2500 Philadelphia school 
children of all grades : 

Per cent. 

Emmetropia 11.19 

Hyperopia, simple 31.23 per cent ") ^. ^, 

with Astigmatism 42.81 per cent j 
Myopia, simple 2.68 per cent ] T? 70 

with astigmatism 11.02 per cent j 
Mixed astigmatism 1 . 07 

Headache, fatigue, inability to concentrate the attention or to 
study result from eyestrain, and a careful examination should be 
made in all cases. 

BLEPHARITIS. 

Definition. — An inflammation of the margin of the lids which 
is quite frequent in children. 

Etiology. — An infection of the hair follicles is usually the be- 
ginning of the process. The squamous and ulcerative types are 



^Cornell: Monthly Cyclopedia of Practical Medicine, March, 1908. 

187 



188 THE DISEASES OF CHILDREN. 

recognized. Predisposing causes are eyestrain, dust and smoke 
which result in a congestion of the mucous membrane of the lids. 
The exanthemata, tuberculosis, anemia and a general run-down 
condition also predispose to it. It is usually found in connection 
with conjunctivitis, both catarrhal and phlyctenular, and often 
with eczema of the face. ^ 

Symptoms. — In the milder form there may not be many focal 
symptoms beyond a scaliness of the edge of the lids, which carry 
away a few hairs when brushed off. In acute cases there is a 
burning and itching sensation of the margin of the lids and 
some photophobia; after a duration of some days the edges of 
the lids are much congested and swollen and bathed in a thick 
yellowish secretion. 

Treatment. — In the squamous form after removal of the 
scales, which can be accomplished by washing with an alkaline 
solution and soap, or softening with vaseline, the local treat- 
ment can be begun. The following can be used to advantage : 

R, Hydrargyri oxidi flav. gr viii 
Vaselini ^i 

M. ft. ung. 

In the ulcerative form they may need the application of a 
1 or 2 per cent solution of nitrate of silver after removal of 
concretions. Generally a tonic treatment is indicated with 
proper hygienic surroundings. 

HORDEOLUM. 

Synonym. — Stye. 

Etiology. — An infection of one of the glands of the eyelid 
or an eyelash follicle takes place from an invasion of the staphyl- 
ococcus aureus or other pus-producing organism. As a result 
of the inflammation suppuration takes place, and frequently a 
reinfection results with a succession of them. As predisposing 
cause, blepharitis marginalis is perhaps the most frequent. Eye- 
strain is also a predisposing cause. 

Symptoms. — Pain of a stinging or smarting character and 
edema of the lid precedes the development of the stye. The 
''pointing" of the abscess is usually at or near the lid margin, 



DISEASES OF THE EYE. 189 

and it may rnptnre spontaneously or necessitate an incision to 
evacuate the pus. The pus is usually quite thick and stringy 
in character. 

Styes may develop in quite young children, and when it is 
considered how possible it is for an infection to take place in 
the child as it plays upon the floor and rubs its eyes with its 
fists it is a wonder they are not oftener seen. I have recently 
seen one in an infant of six months. 

Treatment. — The abortive treatment is occasionally success- 
ful, viz. : Cold applications and pulling out a lash when root 
is infected, or the application of a 30-grain-to-the-ounce solu- 
tion of sulphate of zinc. If the upper lid is affected, it is pulled 
down over the lower lid and the solution painted over its edge 
with a cotton-covered match or tooth pick. The solution is not 
allowed to touch the conjunctiva of the eye. The applications 
.are repeated several times during the day. 

The injection of carbolic acid to abort the boil cannot be even 
considered in the child. 

If a blepharitis marginalis is present the use of a yellow 
oxide of mercury ointment (gr. ii to oi) may bring about a 
cure promptly enough to prevent a stye from forming. 

If the edema continues and the collection of pus does not 
take place quickly, much relief can be had by the application 
of poultices, small squares of flannel wrung out of hot water 
and laid over the affected eye. As soon as pus formation is 
assured, it should be evacuated with a triangular knife. The 
hot applications should be continued while there is a free flow 
of pus, and this followed by the yellow oxide ointment. 

CONJUNCTIVITIS. 

Two varieties may be seen, simple catarrhal conjunctimtis or 
the epidemic or contagious conjunctivitis, the latter being called 
pinh eye. 

Etiology. — This is due to the invasion of the conjunctivae with 
bacteria, the pneumococcus and the Weeks bacillus being most 
frequently the cause. Bacteria-laden dust may be the active 
cause. Common use of towels is a frequent manner of dis- 
semination. 



190 THE DISEASES OF CHILDREN. 

Symptoms. — The simple catarrhal form is much milder in all 
its symptoms, and in its duration also. There is a burning and 
smarting of the eyes and lids, and a feeling as if something were 
in the eye and that lids must be rubbed frequently. There is 
early and profuse lacrimation, and the lids are stuck together 
when the child awakens. 

In the acute form there is an injection of the entire con- 
junctiva and the lid mucous membrane is frequently much 
swollen. When the lids are everted the conjunctival surface 
will be found covered with mucus or muco-pus. It is rare that 
only one eye is affected. 

Treatment. — Much can be accomplished by local treatment. 
The eyes should be irrigated four or five times daily with a 
warmed 3 per cent solution of boracic acid, and one or two 
drops of the following solution dropped into each eye three 
times a day : 

li Zinci sulphatis gr. ss 

Acidi boracici gr. x 

AqiitE comphorat. 
Aquae destillat. aa 3SS 

M. ft. sol. 

A mild boracic acid ointment is rubbed into the lids each night 
or before the child is put to sleep during the day in order to 
prevent the troublesome matting together of them. 

Argyrol in 10 or 12 per cent solution can be used if the secre- 
tion is profuse and purulent. In the severer cases the applica- 
tion of cold compresses is most helpful and soothing. 

Protection from strong light and winds should be insisted upon 
also, and no reading indulged in. 

TRACHOMA. 

Synonyms. — Granulated Lids; Granular Conjunctivitis. 
A chronic infectious, inflammatory condition of the palpebral 
conjunctiva, with the formation of oval masses in the membrane. 

Etiology. — This disease is much more frequent in children, 
though no age is exempt. Unhygienic surroundings, filth and 
improper food predispose to it. The specific organism has not 
been isolated, though a small double coccus has been described 



DISEASES OF THE EYE. ' 191 

by Sattler, and a fungus by Muttermilch. The latter has been 
termed microsporosa trachomatorum. Indiscriminate use of the 
same towel, especially at school and in institutions is one of the 
ways this is spread. 

Pathology. — At first there is a minute granular hypertrophy 
of the mucous membrane of the lid conjunctiva without involve- 
ment of the eye conjunctiva or cornea. There follows a deep 
injection and thickening of the mucous membrane and develop- 
ment of the larger granular masses or follicles, which are minia- 
ture lymph glands. After a varying length of time the stage of 




Fig. 46. — Roller forceps for trachoma. 

cicatrization follows. The granules coalesce, small cicatricial 
bands appear, the area of conjunctival surface is less, the rough- 
ened lids scrape the eye and ulcers of the cornea form. Tra- 
choma occurs with rarity in the negro. 

Symptoms. — During the first of the granular stage there may 
be no symptoms. There is little or no discharge, and the lids 
do not adhere in the morning. After the granules have formed 
there is pain in the eyelids and a feeling as if sand were in the 
eyes, discharge is profuse, mucopurulent in character, photo- 
phobia is present and swelling of the lids takes place. At this 
time the ocular conjunctiva becomes injected. The lids are 
everted with difficulty owing to the swelling of the mucous mem- 
brane. These acute symptoms may subside spontaneously, and 
the condition develop into a more or less chronic one, with 
slight lacrimation and mucopurulent discharge. The glands 
at the angle of the jaw and behind the ear may become enlarged. 

Prognosis. — Even under proper treatment the prognosis is 
not very good. It is essentially a chronic condition, relapses 
are frequent, even in the apparently cured. 

Sequelae. — Opacities and pannus of the cornea; entropion and 
ectropion; distichiasis and symUepharon. 



192 THE DISEASES OF CHILDREN. 

Treatment. — Prophylaxis is of the greatest importance. In 
institutions, children with trachoma should be quarantined. 
Shower baths should be installed in all institutions, as the 
bathing of several in one tub, as frequently will occur if tub- 
bathing is practiced, may be the cause of its dissemination. Indi- 
vidual towels, handkerchiefs and beds should be insisted upon. 

Since the introduction of the newer silver salts, protargol has 
been recommended as giving good results in the acute stage. 
Every other day a 40 per cent solution is painted over the dis- 
eased surface, and a 10 per cent solution instilled into each eye 
twice daily. Other remedies suggested are the following: Solu- 
tion of bichloride of mercury (1:5000) painted on the lids and 
1:15,000 as eyedrops; formalin (1:3000), and the application 
of sulphate of copper crystal direct to the diseased surface. 

Surgical treatment consists in the use of the roller forceps, 
under general anesthesia. 

GRANULAR CONJUNCTIVITIS. 

A much milder form of conjunctivitis than trachoma may be 
encountered in which there is a deposit of very fine granules in 
the conjunctiva. 

The symptoms and course are much less severe, and the dura- 
tion shorter. 

Treatment. — The response to treatment is usually much more 
prompt in. this variety. The silver salts are efficient and bring 
a speedy cure if properly applied. They are used the same as 
in trachoma. 

VERNAL CATARRH OF THE CONJUNCTIVA. 

This form of conjunctivitis has recently been recognized by 
the authorities. 

It is frequent in children during the summer months, and 
consists of a lymphoid hypertrophy of both the palpebral and 
ocular mucous membrane, and especially around the cornea. 

It is intractable, has a tendency to recur and passes away, 
often uninfluenced by treatment, as the summer heat disappears. 



DISEASES OF THE EYE. - 193 

DIPHTHERITIC CONJUNCTIVITIS. 

Etiology. — The Klebs-Loeffler bacillus is the cause of this 
form of conjunctivitis, but it rarely exists alone, being com- 
plicated by other pus-producing organisms, especially the strep- 
tococci azid staphylococci. 

Pathology. — The process in the conjunctiva as the result of 
the invasion of the Klebs-Loeffler bacillus is the same as in other 
mucous membranes. The formation of the pseudomembrane 
occurs within 24 hours after the first congestion. The super- 
ficial epithelia are destroyed and the pseudomembrane dips 
down into the conjunctiva, leaving a bleeding surface when it 
is detached. The ocular conjunctiva may be involved in the 
same process. 

Symptoms, Focal. — There is a great swelling of the mucous 
membrane of the lids, with intense congestion. Lacrimation is 
not profuse at the first, the discharge is thick and blood tinged. 
Later the discharge becomes thinner and purulent. The pseudo- 
membrane forms in 24 or 36 hours. Bacteriologic examination 
may be needed to determine the exact nature of the condition. 

General. — The child looks sicker than in any of the other 
conjunctival inflammations. There is an elevation of from 2° 
to 5° F. in the temperature. 

Treatment. — As soon as a pseudomembrane is seen 2500 to 
3000 units of antitoxin must be administered, without waiting 
for the result of the bacteriologic examination. The same rules 
obtain here as to the second dose of antitoxin as in pharyngeal 
or tonsillar diphtheria. 

For great ecchymosis, cold application to the lids, and nitrate 
of silver solution, 1 to 1.5 per cent, to the conjunctivae after the 
removal of the membrane. 

Ulcer of the cornea is to be feared if the swelling of the lids 
is marked and pressure very great. 

PHLYCTENULAR CONJUNCTIVITIS. 

Synonyms. — Scrofulous conjunctivitis; eczematous conjunc- 
tivitis. 

Etiology. — As indicated in the name given this disease, a 



194 THE DISExVSES OF CHILDREN. 

marasmic, tubercular or otherwise debilitated condition, pre- 
disposes to this form of conjunctivitis. It also follows or com- 
plicates blepharitis marginalis; acute conjunctivitis, eczema of 
the face or lids. The staphylococcus aureus has been found in 
the fluid of the phlyctenule. It rarely occurs in adults. 

Pathology. — The phlyctenules are nodules on the conjunctiva 
or cornea, formed by an accumulation of small cells on the base- 
ment membrane and pushing up the superficial epithelial cells. 
An enlargement of the blood vessels occurs and they radiate, 
spoke-like, from the phlyctenule. The surface of the phlyctenule 
or nodule softens and the contents escape, leaving a small ulcer 
on the conjunctiva or cornea. 

Symptoms, Focal. — The principal symptoms are lacrimation 
and photophobia. There is some discharge which runs down 
upon the cheek and may cause an eczematous condition there. 
A nasal catarrh is present also. There is usually a character- 
istic pose in these cases, the child burying its face in the neck 
of mother or nurse, or holding eyes in bend of elbow. The 
appearance of the eye is described under pathology. 

General. — The child looks run down, is pale and anemic, 
tongue is coated, and the digestion may be upset. 

Treatment. — If the injection of the conjunctiva is very great 
a solution of atropia, 1 or 2 grains to the ounce of 50 per cent 
boracic acid solution, may be instilled. An application of the 
yellow oxide of mercury ointment (gr. i to 3i) is made once or 
twice daily. A piece of the size of the end of a match is put 
between the lower lid and eyeball and the lid closed. Dry 
calomel may be applied to the ulcer with advantage when it 
forms. 

Generally, a tonic is always indicated in these cases. A solu- 
tion of the hypophosphites, glycerophosphates or cod liver oil will 
be of benefit. 

The diet should be regulated and much fresh air insisted upon. 
Study and use of the eyes should not be allowed. Dark glasses in 
the older cases will give great comfort. 



DISEASES OF THE EYE. 195 

OPHTHALMIA NEONATORUM. 

Etiology. — Due to the entrance of the gonococcus into the con- 
junctival sac during the passage of the head through the cervix 
and vagina. The colon bacillus or the pj^ogenic organisms may 
be the cause of a milder inflammation. If it occurs in later life 
it is caused by the accidental inoculation of the eye with the 
gonococcus. 

Prophylaxis. — The instillation into each eye of 1 drop of a 
2 per cent solution of nitrate of silver, as advocated by Crede, 
followed by an irrigation of normal salt solution, will prevent 
ophthalmia. Its use should be universal and not reserved for 
those children whose mothers are suspected of having a specific 
vaginitis at the time of the labor. 

For those who prefer a substitute for the nitrate of silver, 
because of fancied irritation following its use, a 10 per cent 
argyrol solution is recommended. 

Focal Symptoms. — Usually on the second or third day the lids 
of one or both eyes are stuck together, and when separated a 
profuse discharge escapes. The discharge is distinctly purulent 
and may run down on to the cheek. The lids rapidly become 
swollen and the mucous membrane intensely congested, making 
it difficult to evert them. If the secretion remains pent up be- 
tween the lids an ulceration of the cornea may result. 

Great pain evidenced by crying and restlessness is present; 
there is marked photophobia, and unless the hands are pinned 
down the eyes will be rubbed. 

Prognosis. — This form of inflammation is one of the most 
serious to be encountered. More cases of blindness result from 
a specific conjunctivitis than any other. Magnus reports that 
24 per cent of inmates of institutions for the blind in Europe 
have lost their sight from ophthalmia, and statistics show an 
equal or greater number in this country. Upon prophylaxis, 
and promptness of treatment alone, success depends. 

Sequelae. — In the severe cases, as a sequence, the following 
conditions may be found : Anterior staphyloma ; ulceration and 
necrosis of the cornea leaving an opacity which may seriously 
impair vision; or an anterior synechia. 



196 THE DISEASES OF CHILDREN. 

Case. — In one of the few cases in my experience in which 
I failed to employ the Crede method of prophylaxis, an ulcera- 
tion of the cornea in both eyes followed a severe ophthalmia and 
an evacuation of the contents of both globes. In this case, an 
institution one, the silver was not used, as the bottle containing 
the solution was turned over and its contents lost. When it was 
used the next morning it was too late, as evidences of inflamma- 
tion were present. This one unfortunate case has been a con- 
stant reminder to use the silver in the eyes of every new-born 
baby. 

Treatment. — Good results can be had only by beginning the 
treatment promptly; the treatment must be not only unremit- 
ting but intelligently prescribed and administered. To verify 
the diagnosis a smear of the purulent discharge should be made 
upon a slide, stained with methylene-blue and examined for 
the gonococcus. As the symptoms are so rapid in development 
the beginning of the treatment should not wait upon the micro- 
scopic report. 

A day and night nurse should be employed. The eyes should 
be irrigated with a boracic acid or normal salt solution once 
every hour in the 24. The first thought, if only one eye is af- 
fected, should be to prevent the infection of the other. The child 
lying upon the affected side with face held over a basin, the solu- 
tion is directed into the inner canthus of the affected eye, with 
the lids opened as far as it is possible. This irrigation should be 
gently done to avoid abrasion of the cornea, and the fountain 
syringe not held over 12 inches above the head. 

Between the irrigation, unless the secretion is thin and watery, 
the eye is kept covered with ice cloths. Cotton goods is cut 
into 1-inch squares, and these are kept attached to a block of 
ice in a basin near the bedside. As they are removed from 
the eye they are destroyed and fresh ones applied every 15 
minutes. This treatment has been objected to hy some as it is 
thought to be impracticable to apply the cloths effectively, but 
they are of the very greatest benefit when properly applied. 

Silver solution in some form must be applied, nitrate of 
silver in a 2 per cent solution, or argyrol or protargol in a 40 
per cent solution, once daily. It is claimed for the latter 



DISEASES OF THE EYE. 197 

solutions that they are more penetrating; than the nitrate. The 
nitrate can be used in the morning and a weaker solution (10 
to 20 per cent) of argyrol two or three times during the day. 

If it is possible to do so the solution should be applied to 
the everted lids by a cotton swab, but this may be impossible 
on account of the great swelling of the lids. In this event the 
solution should be instilled as thoroughly as possible. 

To evert the eyelids of a child Vail ^ recommends the fol- 
lowing method: 

The surgeon sits with the child's head lightly clamped be- 
tween his knees, the child's body in the lap of the nurse, sitting 
close by in a chair, and the child's hands held by the nurse. 
The feet are allowed to kick free. The entire finger nail of 
the left index finger is placed on the lower lid and the finger 
crooked so that the pulp of the finger tip will just override the 
edge of the lower lid ; then the upper lid is gently pushed down- 
ward by means of the index finger of the right hand, placed 
at the upper tarsal rim, until the free border of the upper lid 
overrides the pulp of the finger tip of the left index. IMain- 
taining the pressure with the right index finger when this posi- 
tion is affected, the upper lid is turned inside out by simply 
keeping the free edge of the upper lid against the pulp of the 
index finger of the left hand. The right hand is now free to 
use in everting the lower lid. Having everted the upper lid, 
the lower is easily everted by making pressure downward with 
the right thumb. 

The protection of the sound eye by a watch crystal held in 
place by adhesive strips has been recommended by Buller, and 
in older patients is practical. The hands of the infant should 
be held down by pinning the sleeves to the front of its dress. 

Regularity of feeding and tonic treatment, if case is pro- 
longed, is recommended. 

PTERYGIUM. 

This is an uncommon condition in children. It consists of 
a circumscribed hypertrophy of the conjunctiva, quite regularly 
triangular in shape, containing enlarged blood vessels, and the 



1 Jourual of Ophthalmology and Otolaryngology, December, 190' 



198 THE DISEASES OF CHILDREN. 

apex of the area pointing toward the cornea. The vessels enter 
at the base. - 

Etiology. — Two varieties are usually described, pseudopter- 
yyium and true pterygium. In the first, the condition seems 
more like a formation of cicatricial bands following a violent 
inflammation such as a gonorrheal or diphtheritic conjunctivitis, 
or trachoma. The latter form has been ascribed to the long 
exposure of the eyes to heat, or the sun's rays, as on the water, 
wind, dust, etc. 

Symptoms. — These growths usually occur on the nasal side 
of the eyeball, though the whole horizontal, central area of the 
ball may rarely be involved. The growth gives practically no 
pain or inconvenience, but is very unsightly. 

Treatment. — Surgery offers the best results, and excision is 
the best method of dealing with it. 

DISEASES OF THE CORNEA. 

Phlyctenular Keratitis. 

Etiology. — The same conditions causing phlyctenular con- 
junctivitis cause a phlyctenular keratitis, and, in fact, they 
usually occur simultaneously. It occurs most frequently be- 
tween the ages of 2 and 12 years. 

Symptoms. — The same symptoms that are present in phlyc- 
tenular keratitis; the photophobia and lacrimation are more 
severe. According to the location of the ulcer is the sight 
affected. If over or near the pupil the sight may be greatly 
impaired, owing to the opacity of the cornea. The pose referred 
to in the description of the conjunctival variety is more con- 
stantly maintained. The eyes may have to be forced open for 
inspection because of the photophobia. Lacrimation is profuse, 
and mucopus is present in most of the cases. When one or 
more phlyctenules are seen at the margin of the cornea, over- 
lapping both the cornea and conjunctiva, they are called mar- 
ginal plilyctenulcs. 

Treatment. — Atro])ia instilled into the eye is very necessary, 
using, perhaps, a slightly sti'ongei' solution ( gi'. ii or iii to f^i). 
The same strength of yellow oxide of mercury ointment is of 



DISEASES OF THE EYE. 199 

value in this form. Boracic acid irrigations should be used three 
or four times a day. A general tonic treatment is also in- 
dicated. The photophobia may often be overcome by immersing 
the face in a basin of cold water for a few seconds several times 
a day. 

Insterstitial Keratitis. 

This is the form of inflammation of the cornea first described 
by Hutchinson as occurring in congenital syphilis. It occurs 
generally in children, and is most frequent between 5 and 12 
years of age. It is generally bilateral. 

Pathology. — There is an inflammation and infiltration of the 
cornea with formation of fine blood vessels deep in the corneal 
tissues, and an injection of the conjunctiva. The infiltration 
is uneven. There may be an opacity of the entire cornea. If 
recovery takes place there may remain some fine lines running 
through the cornea, which were the former vessels. 

Symptoms. — There is lacrimation and photophobia but not 
much pain. Sometimes there is a spasm of the lids. Asso- 
ciated with this disease are the peculiar notched or Hutchinson 
teeth; the skin lesions occurring in syphilis; the facies, and 
labyrinthine deafness. 

The duration is chronic, recovery rarely occurring sooner 
than two or three years. Atropia is of great help in obtaining 
comfort and should be used for its effect two or three times 
daily in solution 3 to 4 grains to the ounce. In the very acute 
stage the patient may have to be placed in a dark room, but 
usually comfort can be had by use of dark glasses. Application 
of hot cloths is of great comfort, in presence of spasm of the 
lids. Difference of opinion exists as to the value of yellow 
oxide of mercury ointment. It should be used only when the 
severe inflammatory symptoms have subsided, and in connection 
with massage is of benefit. 

In the acute inflammatory stage atropin is used with the hot 
applications on account of the probability of an iritis developing. 

Internally luorcury is indicated early and late and contin- 
uously for a number of weeks. Iron and cod liver oil are also 
important, in connection with good food. 



CHAPTER XI. 

DISEASES OF THE RESPIRATORY ORGANS. 

FOREIGN BODIES IN THE RESPIRATORY TRACT. 

Owing to the frequency with which children place foreign 
bodies in the nose and mouth, the comparative infrequency of 
the aspiration of these bodies in the bronchial tubes is to be 
wondered at. Any small body may find its way into a bronchial 
tube, as a glass bead, a pea or bean, a pebble, etc. 

Symptoms. — A child while at play, usually entirely well, is 
seized suddenly with a paroxysm of coughing, followed by 
dyspnea, which may be quite severe, there being a decided blue- 
ness of the face. If the object is of sufficient size to obstruct 
the larynx the child wdll succumb from asphyxiation ; if it 
lodges in a bronchus, there may be no more than frequent repeti- 
tion of the paroxysmal coughing. Owing to the large size of the 
right bronchus, and the angle at which it arises from the trachea, 
the bodies usually lodge on this side. An X-ray examination 
may be necessary to locate the body, provided it is of the nature 
which will show upon the negative. 

Physical signs may aid the diagnosis. If the obstruction is 
complete there is absence of the respiratory murmur and voice 
sounds on that side, though at first there may be resonance due 
to the retention in the vesicles of the air in the lung at the time 
of the obstruction. This . air is soon absorbed and dulness is 
found over the entire lung. 

Owing to the irritation and bacterial invasion a broncho- 
pneumonia is very liable to develo]\ or a localized abscess. 

Diagnosis. — "With the history detailed above, the aspiration 
of a foreign body should always be suspected. The presence of 
a paroxysmal cough of very sudden onset without previous 
coughing is suggestive. A diagnosis from whooping-eougli 
nuist be made, which should be easy, as whooping-cough does 
not begin as suddenly. 

200 



DISEASES OF THE RESPIRATORY ORGANS. 



201 



Treatment. — If the diagnosis is made as soon as the aspira- 
tion occurs it may be dislodged by quickly grasping the child 




Fig. 47. — Five-cent piece in esophagus. (Reproduced through courtesy of Di 

Edward Bruce.) 



by the feet, suspending it inverted and shaking it. If not at 
once thrown off the spasm produced in the glottis prevents its 
expulsion. 



202 THE DISEASES OP^ CHILDREN. 

If the foreign body can not be dislodged by the above procedure, 
it should be taken to a hospital, and the X-ray picture made 
as it furnishes a very valuable guide to the operator. 

The success obtained by the direct inspection of the trachea 
and bronchi by specially devised instruments for the removal of 
foreign bodies in the bronchi is remarkable. 

Killain and Jackson have devised most ingenious and useful 
instruments for direct laryngoscopy, tracheoscopy and broncho- 
scopy, which with the skiagraph as a guide, and direct illumina- 
tion, enables the operator to see the foreign body and with 
specially designed forceps it is grasped and removed. 

Jackson gives the following measurements of the tracheo- 
bronchial tree : 

Child Infant 

Diameter trachea 8-10 mm 6-7 mm 

Length " 6 cm 4 cm 

" Right bronchus 2 cm 1.5 cm 

Left " 3 cm 2.5 cm 

" Upper teeth to trachea 10 cm 9 cm 

" Total to secondary bronchus.... 19cm 15cm 

ASTHMA. 

Bronchial asthma is comparatively infrequent in infancy, 
though not uncommon in childhood. 

Etiology.— In this condition there is a vulnerable area of 
mucous membrane and an abnormally sensitive nerve center and 
an irritant as the active causative factor. The vulnerable area 
of mucous membrane may be in the nares, adenoids, the bronchi, 
or the gastrointestinal tract. 

Symptomatology. — The attack is not unlike that seen in the 
adult. It may be preceded by a rhinitis or a bronchitis or an 
attack of acute indigestion with or without vomiting. There 
is decided dyspnea, increased in the recumbent posture. There 
is difficulty both in inspiration and expiration, with a frequent 
tight cough, there is an anxious expression and the skin is moist 
with more or less cyanosis, according to the amount of ol)struction 
to the breathing. 

Physical Signs. — Tnspvciion shows the extraordinary mascles 
of respiration being called into play, recession of the suprasternal, 
supraclavicular and intercostal spaces, with more or less cyanosis 



DISEASES OF THE RESPIRATORY ORGANS. 203 

or lividity. On palpation rhonchal fremitus may be felt if there 
is much spasmodic condition of the larger tubes. On ausculta- 
tion widely distributed dry rales, sonorous and sibilant, are 
heard on both inspiration and expiration with occasional moist 
rales in the larger tubes. Coughing may dislodge the mucus 
causing the moist sounds, or the point of intensity of these may 
be changed. There is hyperresonance on percussion due to the 
temporary emphysema present. 

Treatment. — Prophylaxis is of great importance. Each case 
should be carefully studied and the exciting cause or causes 
determined and removed or remedied. The nose and 
nasopharynx should be rendered as normal as possible, adenoids 
and abnormal tonsils removed, the digestion, and stools closely 
watched. All the methods for the prevention of bronchitis 
should be used, fresh air especially when the child is asleep, 
cool sponge baths after the cleansing bath, followed by brisk 
friction. 

For the relief of the spasmodic condition during the attack, 
it may be necessary to resort to hypodermic medication; three 
to five minims of a 1 :1000 solution of adrenalin chloride has been 
used with much success ; nitroglycerine or occasionally when all 
else fails, a very minute dose of morphine. By the mouth 
ipecac or antimony and ipecac (aa gr. 1/100) cough tablets 
frequently aiford much relief. 

ATELECTASIS, PULMONARY COLLAPSE. 

This is a condition in which a lobule or lobe of the lung is 
collapsed. It is principally found in new-born infants, though 
a collapse may occur at any time. 

Etiology. — A plug of mucus inhaled by a new-born with its 
first inspirations may lodge in a bronchus leading to an alveolus 
and completely shut off the air from this part, followed by a 
collapse of that portion. The same condition may occur in 
bronchitis in later life, or after the aspiration of a foreign body 
into a larger bronchus. 

Pathology. — There is a collapse of the alveoli of the lung, 
and may be limited to a small area singly or scattered through 
the lung. The affected areas are like liver in appearance, and 



204 THE DISEASES OF CHILDREN. 

are depressed below the general surface of the lung. There may 
be small areas of emphysema surrounding them. 

Symptoms. — In the new-born there may be no physical signs 
or symptoms by which the condition can be recognized early. 
Later, if extensive, there is a sinking in of the chest on that 
side, or if scattered there may be no evidence of the condition 
except an impairment of the breath sounds over the affected 
area, with localized dulness, perhaps. 

In late cases, and extensive collapse, absence of breath sounds, 
harsh breathing, dulness and collapse of the chest wall are diag- 
nostic points. 

Treatment. — The prompt removal of mucus in the naso- 
pharynx of the new-born will prevent its aspiration into the 
bronchi, inversion of the child and obtaining free inspiration 
and crying aids in the dilatation of the bronchi and dislodging 
of dry mucus which may have been aspirated. 

In older children, when it follows bronchitis, a dose of ipecac 
for its physiological effect, the mucus being dislodged during 
vomiting, is efficient in dislodging obstructing plugs. Frequent 
spanking to make it cry and cause deep inspiration ; alternate 
hot- and cold-baths, for the effect of causing a shock to the skin, 
cause deep inspiration. 

ACUTE CATARRHAL BRONCHITIS. 

This is an inflammation of the mucous membrane of the 
bronchi, large or small, or both, with no involvement of the 
peribronchial tissue. 

Etiology. — The primary and exciting cause is some micro- 
organism, as the influenzal bacillus, the strepto- and staphylo- 
cocci, etc. A dust-laden atmosphere, draughts, sudden ex- 
posures Avith chilling of the entire surface, and wet feet, may 
act as a direct exciting cause. It may occur secondarily to the 
acute exanthemata and to diphtheria, and is a frequent occur- 
rence in children who are the subject of adenoids and chronic 
nasopharyngeal catarrli. Children who are convalescing from 
acute attacks of diarrhea are prone to develop bronchitis, from 
lowered resistance. It is a frequent complication of whooping- 
cough, increasing the severity of this condition greatly. 



DISEASES OF THE RESPIRATORY ORGANS. 205 

It occurs in rachitis and other nutritional disorders from a 
lowered power of resistance. 

Pathology. — There is primarily a swelling of the mucons 
membrane of the larger bronchial tubes, with deep injection, 
followed ciuickly by a secretion which is largely serum at first, 
then mucopurulent as the disease progresses. It is usually 
bilateral and rarely in patches, even when the smaller tubes are 
involved. The inflammation is limited to the mucous mem- 
brane, and when it spreads to the peribronchial tissue the proc- 
ess becomes a bronchopneumonia. If there is a plugging of 
some of the smaller or capillary bronchial tubes the portion of 
the lung supplied by these tubes collapses. 

Symptoms. — If there has been a primary tonsillitis or Isltjji- 
gitis, a low fever and slight cough precede the active symptoms 
of the bronchitis. It may begin as an acute coryza, with sneez- 
ing, discharge from the nose, and lacrimation. In mild eases, 
in which the process is chiefly limited to the larger bronchial 
tubes, there may be but few symptoms, malaise, slight rise in 
temperature, loss of appetite and cough. A child under five 
years of age, uninstructed, will swallow all mucus raised in 
coughing. 

In more severe cases in which the smaller tubes are involved, 
the child is acutely sick from the beginning. There may be 
vomiting; the temperature rises to 102° F. or 103° F., and with 
the development of the cough there is rapid breathing, with 
wide dilatation of the alae nasi. The dyspnea is frequently 
severe, and if any coryza exists it is difficult for the child to 
nurse. This is especially true where there are nasopharyngeal 
adenoids. 

There is not usually a wide variation in the temperature be- 
tween morning and evening. There may be an evening drop 
and a morning exacerbation in rare cases. The temperature 
usually lasts four or five days, though it may last for a week. 
It is more easily controlled by hydriatic treatment than the 
fever of bronchopneumonia. 

The respirations are hurried, frequently as high as 80 per 
minute, and there may be a decided pallor of the skin of the 



206 THE DISEASES OF CHILDREN. 

face. When asleep the skin of the head may be bathed in 
perspiration. 

The bowels may be disturbed, especially in young children, 
and the actions contain much mucus which has been swallowed. 

Physical Signs. — Inspection of the bared chest shows in severe 
cases an employment of the extraordinary muscles of respiration, 
and if there is much spasmodic contraction of the bronchial tubes 
a recession of the suprasternal and clavicular notches. The 
respiration is quite hurried. 

Palpation of the chest in the first stage may be negative, but 
during the second stage when there is a secretion of mucus 
and mucopus, rhonchal fremitus is easily felt, owing to the thin- 
ness of the chest wall. For this reason and because of the large 
tubes, percussion is of little assistance as a diagnostic measure in 
this and some other of the pulmonary diseases of childhood. 

In the first stage, before secretion has occurred, auscultation 
reveals sonorous rales if only the larger tubes are affected, and 
sibilant rales when the smaller tubes are involved. Those rales 
are general in distribution, but heard loudest at the apex. "With 
the advent of the second stage on the second or third day, with 
mucus thrown out, moist rales are heard. They are large and 
small according to the lumen of the tube involved. If coughing 
occurs when auscultation is being performed, a small area of 
lung may be found free from rales entirely for a short while. 

Through the rales may be heard the normal vesicular breath- 
ing, though over the suprascapular and interscapular regions 
the vesicular sound is replaced by a harsh, high-pitched expira- 
tory sound simulating bronchial breathing. This fact should 
be borne in mind. 

Diagnosis. — The principal diagnosis is from a broncho- 
pneumonia, which may not be possible clinically. A localiza- 
tion of the physical signs of bronchitis and a continuation of 
the above symptoms beyond four or five days is very suggestive. 
Dulness over a limited area is also suggestive of consolidation or 
collapse of a more or less large area of lung. In pneumonia 
there is more dyspnea and the expiratory grunt more likely 
to be present. 

Prognosis. — Older children with acute catarrhal bronchitis 



DISEASES OF THE RESPIRATORY ORGANS. 



207 



usually recover promptly in four or five days; in infants, until 
entire subsidence of symptoms the condition should be con- 
sidered serious, because of the possibility of an extension of the 
process through the thin bronchial wall and the development of 
a bronchopneumonia. 

In the secondary cases, especially following measles, the prog- 
nosis should always be guarded. 

Treatment. — The child should be kept in one room, if pos- 
sible, heated by an open fireplace, with windows open at the 




Fig. 48. — Vaporizer. 

top and the temperature kept as evenly as possible at between 
60° F. and 65° F., never as much as 70° F. The patient should 
be kept in bed, and several times a day a tent made over it with 
a sheet and the air impregnated with moist air from a so-called 
croup kettle or steam spray, which can be medicated with ben- 
zoin or eucalyptus. 

But little internal medication should be given, beyond a 
preliminary calomel purge. Frequent doses of syrupy cough 
mixtures have no place in the treatment of bronchitis. 

During the first stage the following tablet is of decided 
benefit : 

I^ Tartar emetic 

Powd. ipecac aa gr. 1-100 
Sacch lactis q. s. 
M. ft. Tablet No. 1. 



208 THE DISEASES OF CHILDREN. 

These may be given every two hours to a child a year old, 
unless vomiting occurs. Dover's powders in small doses, gr. -J 
or 1, or codeine sulphate, gr. -J or i, may be given when the 
child is put to bed for the night, if the cough is so persistent 
as to prevent its sleeping. In the presence of a sensation of 
tickling in the throat, adding to the cough, the application of 
a cold, wet compress to the neck, protected by a wide, dry 
flannel, is of great benefit. 

No medicinal antipyretics should be given, the temperature 
controlled by hydrotherapy entirely. 

Counter irritation of the chest is of the greatest benefit, mus- 
tard plaster giving the best results. One part of Coleman's 
powdered mustard is mixed with 6 or 8 parts of flour into a 
thick paste with cold water, spread between two thin layers 
of cloth, warmed before the fire and applied to the skin. An 
edge is lifted from time to time to ascertain the depth of the 
redness of the skin. When the skin is quite red the plaster is 
removed and the surface greased with vaseline. Enough paste 
should be mixed to make two plasters, which are applied back 
and front at the same time. They are very soothing, as a rule, 
to a restless, dyspneic child, until they begin to burn, and help 
the cough. They should be reapplied when the skin is pale 
enough to allow it, probably as often as every six hours. With 
scanty urine, a teaspoonful of liq. ammon. acetatis in water 
every three or four hours is of benefit. 

Stimulating expectorants can be given older children when 
the secretion has changed, as 



I Ammon carbonat 


5ss 


Vin ipecac 


5ii 


Syr. laurecerasi 


Sss 


Aquae dest. q. s. ad 


Bii 


i. ft. Sol. 




ig. One teaspoonful every three hours 



Prophylaxis is of the greatest importance. Children subject 
to lymphatism with adenoids and enlarged tonsils, should, in 
the spring or summer, have these removed. The importance of 
fresh air should be emphasized; children should not be started 
to school under seven years of age. They should have a daily 



DISEASES OP THE RESPIRATORY ORGANS. 209 

morning bath, followed by a cool sponge and a brisk rub until 
a vigorous reaction is obtained. The cold spinal douche is a 
great shock and not well borne by the average child. 

The sleeping of the child out of doors should be encouraged, 
the only consideration being that it be protected from draughts 
and wind. 

The sleeping room at night should preferably not have been 
used during the day, and if it has, should be thoroughly aired 
before the child is put to bed. The temperature should not be 
above 65° F. 

The barbarous custom of ''hardening" a child by keeping it 
without shoes or stockings at all seasons is responsible for many 
of these attacks. 

Older children in colder climates should Avear under- 
drawers as soon as bladder control has been established, as 
there is always a space from stockings top and drawers entirely 
uncovered. 

CHRONIC CATARRHAL BRONCHITIS. 

This affection is a direct sequel of an acute bronchitis and 
occurs in older children who are the subject of nutritional dis- 
orders, as rachitis, lymphatism or organic heart lesions, syph- 
ilis, etc. 

Pathology. — There is a chronic thickening of the mucous mem- 
brane, and numerous patches of dilated bronchi constituting 
either a local or a general emphysema. The mucous membrane 
is bathed wdth mucus and mucopurulent secretion. 

Symptoms. — Cough is the principal symptom, and this is fre- 
quently more distressing at night ; expectoration in older chil- 
dren is sometimes profuse; the cough may be paroxysmal; 
dyspnea is often present; usually there is a very slight rise in 
temperature, not often more than 100° F. There is pallor and 
a clammy skin, the child is listless and has very little endurance, 
showing little tendency to exercise or exhibiting great fatigue 
with an increase of coughing on exertion. 

Physical Signs. — On inspection there is noticed a tendency to 
bulging of the intercostal spaces from the emphysematous con- 
dition. 



210 THE DISEASES OF CHILDREN. 

Percussion shows an exaggerated resonance over the whole 
pulmonary area. 

On auscultation the respiratory murmur is feeble, and numer- 
ous dry and moist rales, large and small, are heard, which may 
be displaced on coughing. 

Diagnosis. — The chief differential diagnosis is from pulmo- 
nary tuberculosis. In chronic bronchitis the physical signs are 
general, the temperature not apt to be as high, the wasting not 
as rapid, the expectoration more profuse. The tuberculin re- 
action may be of assistance in making a diagnosis. From pertus- 
sis the diagnosis should be easy. 

Prognosis. — In children the subject of lymphatism, the prog- 
nosis is not very good. If the cough is relieved on the advent of 
summer the prognosis is better. It is rendered worse by the 
development of any intercurrent disease. 

Treatment. — Nothing is of so much avail in these children as 
a change in climate, even though it be slight. Removal in the 
winter to a warm, salubrious climate, free from dampness and 
winds, in the. pine regions, is of the greatest benefit. A place 
must be chosen where the child can live out of doors. The east 
coast of Florida, the Gulf coast along Alabama and Mississippi 
shores, or the pine regions of North and South Carolina and 
Northern Louisiana. This change should be made in the late 
fall before an attack. 

Forced feeding where this is possible yields excellent results, 
eggs and. milk forming the basis of the extra diet. Sweets of 
all description should be denied rigorously. Cod liver oil gives 
the best possible results, administered pure, 15 to 30 drops 
after eating, if possible. 

Iron in an easily assimilable form is of benefit. 

I^ Tinct. ferri cliloriri 5iss 

Glycerine Jss 

Aquae dest. q. s. ad ^iii 
M. Sig. One teaspoonful diluted after eating. 

EMPHYSEMA. 

This condition is a dilatation of the air vesicles and is asso- 
ciated with bronchiectasis, where the larger and smaller bron- 



DISEASES OF THE RESPIRATORY ORGANS. 211 

chial tubes are dilated from a long-standing chronic inflamma- 
tion of the bronchial mucous membrane. 

Etiology. — It is a frequent accompaniment of chronic bron- 
chitis, and occurs as a complication of whooping-cough from the 
violence of the straining during the paroxysms of coughing. 

Pathology. — There is a weakening of the walls of the bronchi 
and air vesicles from chronic congestion and frequent violent 
stretching from coughing. When limited to the air vesicles it is 
usually termed vesicular emphysema, and in this event the 
symptoms are much more severe. The bronchial tubes and 
vesicles are capable of acute dilatation without serious permanent 
damage, and in such conditions as whooping-cough the resiliency 
of the walls of the tube may overcome the dilatation as the 
disease subsides. 

Compensatory Emphysema always is found in the over-worked 
portion of the lung in pneumonia, and in the unaffected side 
in pleurisy, with effusion or atelectasis. 

The lung is dilated, the diaphragm displaced downward and 
the chest wall bulging to accommodate them. In the severe 
form there is a breaking down of the intervesicular walls and a 
coalescence of the vesicles. 

Symptoms. — In cases of chronic bronchitis in which the breath- 
ing is specially labored, and there is noticed a change in the 
contour of the chest, emphysema should be suspected. There 
is a tendency for the chest to assume the barrel shape, the veins 
of the skin enlarge, dyspnea is a frequent early sign, and the 
least exertion causes fits of coughing which are more than 
usually severe. The heart is dilated and its action often rapid 
and tumultuous. 

Expectoration is usually profuse, especially on awakening, 
and there may be nausea with a severe paroxysm of coughing. 

There is a marked increase in pulmonary resonance and a 
feeble respiratory murmur, which has lost its vesicular quality. 
Vocal fremitus is much lessened and the cardiac area of dulness 
much smaller owing to the overlapping of resonant lung. 

Rales are generally present and other signs of bronchitis. 

Treatment. — This is largely symptomatic ; eliminate the cause 
when possible. When associated with bronchitis this must be 



212 THE DISEASES OF CHILDREN. 

relieved, the best results being obtained by a change of climate. 
The cough, of itself increasing the trouble, should be controlled 
by the administration of a pulmonary sedative: Codeine sul- 
phate, gr. i/g to }4, to child of three or four years, or heroin 
hydrochlorate, gr. ^^2 to ^^4. General tonics are of the utmost 
importance, fresh air, good, nutritious diet, elimination of 
sweets entirely. 

Close watch must be kept on the bowels, as constipation is 
present as a rule and aggravates the condition. Regular enemas, 
cascara aromatic, 10 or 15 drops in water at bedtime. 

BRONCHOPNEUMONIA. 

Synonyms. — Bronchial p^ieumonia; lobular pneumonia; capil- 
lary hronchitis ; catarrhal pneumonia. 

Etiology. — When secondary to an acute or chronic bronchitis, 
there is an extension through the mucous membrane of the bronchi 
and air vesicles, of the inflammatory process. It may be secon- 
dary to the acute exanthemata or diphtheria, the toxins and 
organisms themselves setting up the process. The following 
predispose to bronchopneumonia; malnutrition, rachitis, ade- 
noids, unhj^gienic surroundings, living in institutions. 

It may occur entirely independent of any known disease as 
an acute primary condition, due to any of the organisms caus- 
ing inflammation finding lodgment in the lung. The follow- 
ing organisms have been localized from bronchopneumonia, 
pneumococcus, staphylococcus, streptococcus, Klebs-Loeffler bacil- 
lus, bacillus coli communis. 

Pathology. — There is an inflammation of the bronchial mu- 
cous membrane, the peribronchial tissue and the air vesicles. 
The process may involve a single lobe of the lung, a more or less 
superficial area of the posterior portion or a small spot at any 
place. Frequently on section a number of small areas of con- 
solidation will be found, with smaller areas of atelectasis, and 
patches of emphysema nearby. The cut surf ace is dark and mot- 
tled and frothy mucus or mucopus oozes from the severed bronchi. 
When the consolidated spot is near the surface there is always an 
involvement of the pleura. This area is roughened and covered 



DISEASES OF THE RESPIRATORY ORGANS. 213 

with fibrin. There may be adhesions between the two pleural 
surfaces. 

The bronchial glands are usually considerably enlarged. 

Symptoms. — Primary bronchopneumonia begins suddenly, like 
lobar pneumonia. 

In severe cases the attack usually begins with vomiting, there 
is a cough, though this is not always a prominent symptom. 

Dyspnea and hurried hreatliing are prominent and early symp- 
toms. The temperature is irregular, not running persistently high 
as in lobar pneumonia; it may reach 104° F. but is usually below 
this. Occasionally there is no fever. The pulse is accelerated and 
the respirations hurried ; the ratio is usually 2 to 1 or even 3 to 1. 
The pulse may range between 180 and 200 or higher. The expira- 
tory grunt, which is almost pathognomonic may be present, but 
not with the same regularity as in lobar pneumonia ; there is dila- 
tation of the alse nasi, and there may be more or less cyanosis. 
There is restlessness and prostration. 

If the pneumonic condition arises as a secondary disease there 
is an evidence at once that the child is sicker than it has been for 
a few days ; the respiration and pulse are hurried, the tempera- 
ture rises, cough becomes persistent and harassing. The cough 
is dry and, except in older children when secretion is profuse, 
there is no expectoration. 

The dyspnea causes restlessness at night and the cough se- 
riously interferes with sleep also. The skin is generally more 
moist than in lobar pneumonia, often severe perspiration is seen, 
though it may be hot and dry. The cheeks do not have the deep 
red color as in lobar pneumonia, but are more cyanosed. 

There may be marked nervous symptoms, but convulsions in 
the onset are rare. The bowels are not as a rule disturbed, though 
there may be a diarrhea. The actions are thinner as a rule than 
normal and may contain mucus. "When there is a distension of 
the gastrointestinal tract from gas the dyspnea is further in- 
creased. 

Physical Signs. — No two cases of bronchopneumonia present 
the same physical signs. These may vary from the signs of a 
localized hronchitis to a frank consolidation, limited to a small 
area or involving the most of a lobe. 



214 THE DISEASES OF CHnjDREN. 

Inspection reveals hurried, often labored respiration, pallor, 
dilatation of the alge nasi, recession of the suprasternal, supra- 
clavicular and intercostal spaces, but without wide range of 
motion of the chest, owing to the emphysematous condition of 
the lungs. 

On percussion there is an increased pulmonary resonance over 
all except the consolidated area, due to the compensatory em- 
physema. Even the dulness, found usually over the consolidated 
area, is much diminished on this account. Owing to the thin- 
ness of the chest wall of the infant, percussion is not as valuable 
a means of physical diagnosis as in older children and adults. 
Percussion should be performed very lightly. 

Palpation may reveal rhonchal fremitus and if the consolidated 
area is large vocal fremitus may also be felt. 

Auscultation is of the greatest help in making a diagnosis. As 
before stated, the signs of a localized bronchitis are very suspi- 
cious. The localized, moist rales may be the only signs heard 
which are sufficient for a diagnosis, when taken in connection 
with the other symptoms. They may only be heard on crying or 
deep inspiration. 

Over the anterior chest but little may be heard, unless some 
consolidation appears here. Owing to the emphysema, the re- 
spiratory murmur is enfeebled. Over the posterior aspect, es- 
pecially, every variety of rale may be heard, with areas over which 
pleuritic friction sounds are heard. As there are only scattered 
areas of consolidation, usually the breathing is high-pitched, es- 
pecially expiration. Voice sounds are increased and the sounds 
of the cry are exaggerated very much over this area. 

Convalescence in some cases may be much prolonged, the gen- 
eral symptoms subside, but the chest condition remains un- 
changed, resolution taking place very slowly. These always 
cause much anxiety to the physician because of the possibility 
of the pulmonary condition becoming tubercular. The child 
has a progressive loss in weight and appetite, there is pallor, rest- 
lessness, and possibly diarrhea, etc. 

Complications. — Bronchopneumonia may eventuate in an 
abscess of the lung, gangrene, pleurisy with effusion, empyema. 



DISEASES OF THE RESPIRATORY ORGANS. 215 

any one of which complicate the condition greatly and render 
the prognosis most unfavorable. 

Emphysema and bronchiectasis may result, making recovery 
difficult. Otitis media, meningitis, pericarditis, endocarditis may 
occur as a complication. 

Diagnosis. — The principal diseases from which a bronchopneu- 
monia must be diagnosed are hroncliitis, pulmonary tuberculosis 
and lohar pneumonia. 

Prom bronchitis the diagnosis is usually made both from the 
physical signs and the symptoms, though at times it may be dif- 
ficult to reach a positive conclusion at first. The signs of a 
bronchitis are usually bilateral and general in distribution, while 
the signs of a bronchopneumonia are localized and usually found 
at the bases posteriorly. The child does not seem so ill in bron- 
chitis, though at first the temperature may be higher. The course 
of the disease is shorter in bronchitis. The pulse and respiration 
ratio is not so widely different from normal. 
, In lohar pneumonia the onset is much more sudden, but fre- 
quently the only diagnostic sign will be the uncomplicated bron- 
chial breathing at one place only, as an apex or base, which in 
lobar pneumonia is so frequently the chief sign. Patches of 
high-pitched breathing, not distinctly bronchial, with rales here 
and there is very suggestive of bronchopneumonia. The tem- 
perature in lobar pneumonia runs higher persistently and does 
not fluctuate so much as in bronchopneumonia and ends by crisis. 
Lobar pneumonia is more frequently a primary disease than 
secondary. 

Puhnonary tuherculosis and bronchopneumonia may at first be 
difficult of differentiation, and as a tubercular infection may be 
engrafted on an unresolved bronchopneumonia, it is difficult to 
tell where one begins and the other ends. There is more often a 
history of prolonged ill health in tuberculosis than in broncho- 
pneumonia, and the complication of a meningitis more often 
encountered in tuberculosis during its course. In a prolonged 
pulmonary tuberculosis there is' a persistent and rather regu- 
lar run of elevated temperature. 

Every case of unresolved bronchopneumonia, with a mild rise 



216 THE DISEASES OF CHILDREN. 

of temperature, should be viewed with suspicion, and one of the 
tuberculin tests made to clear up the diagnosis. 

Prognosis. — The prognosis in bronchopneumonia is not nearly 
so favorable as in lobar pneumonia. Primary bronchopneumonia 
is less fatal than secondary, such as may occur as a complication 
of the exanthemata pertussis, diarrhea, diphtheria, etc. 

Dunlop ^ reports 333 cases of bronchopneumonia occurring in 
the Sick Children's Hospital, with a mortality of 28 per cent. 
The prognosis is influenced by the following conditions: Age, 
worse in the very young; the extent of the lung involvement, bad 
in extensive involvement; previous health, when previous health 
has been poor, and when there have been nutritional disorders, as 
rickets, or a gastrointestinal disturbance, the prognosis is unfavor- 
able. 

The general course of bronchopneumonia is much more pro- 
longed than lobar pneumonia, and ends by lysis in practically 
all cases. 

Treatment. — Hard and fast rules can not be laid down for the 
treatment of every case. In a general way those measures which 
will best support and nourish the child, control the temperature 
and decrease respiratory difficulty will bring about the best re- 
sults. 

The best ventilated and sunniest room in the house should be 
selected for the sick room, as far removed from the noise of the 
house as possible. Quiet is very essential. The child should be 
made to remain in its crib and not held upon the lap, as it can 
be protected much better from the air from the open windows in 
the crib, by crib curtains or screen. In winter warm night 
clothes should be worn. There may be much objection to the 
fresh air but firmness and reasoning will usually gain its accept- 
ance as a part of the sick room routine. The usual cleansing 
bath should be given daily. 

The diet in the artificially fed should be reduced in quantity 
and quality, in the breast fed the interval between feedings 
lengthened. Soft diet without meat can be given to older chil- 
dren. Milk should be the basis of the diet. 

Temperature. — Pyrexia and hyperpyrexia if greatly adding to 

1 British Medical Journal, August 15, 1908. 



DISEASES OF THE RESPIRATORY ORGANS. 217 

the discomfort aijd distress of the patient, can be best controlled 
by hydrotherapy. After taking and recording the temperature 
a tepid sponge bath can be given with the child between blankets, 
with alcohol and water, at a temperature of about 95° F. to 
100° F. If there is no fall in the temperature thirty minutes 
after the sponge bath, other hydrotherapeutic measures may be 
used; a full bath reduced from 110° to 95° F. ; compresses wrung 
out of water at temperature of 90° F. applied to the chest ; cold 
pack in the full blooded, sthenic cases ; mustard baths at 105° F., 
for the cyanosed poorly nourished cases. Ice bags to the head are 
of service in hyperpyrexia and when there is delirium. If there 
are scattered areas of consolidation, with hyperpyrexia, harassing 
cough and pleuritic pain, the application of an ice bag to the chest, 
on a half hour, off an hour is of benefit. 

Local Applications. — Poultices, dehydrating agencies, oil silk 
jackets are abominations and should not be used. 

Counter irritation with mustard plasters is of great benefit, 
made into a thick paste with one part of mustard to six or eight 
parts of fiour, mixed with water. This strength will not blister 
or burn badly if removed when the skin is a deep pink. Fresh 
ones can be applied as often as every three or four hours if the 
skin is normal in color by that time. 

The other treatment is largely symptomatic ; if the cough is 
very persistent and annoying at night, codeine sulphate, ^4 ^^ Vs 
grain, is very beneficial; the bowels may need some attention, 
castor oil at the beginning. Ten grains of bismuth subnitrate 
every three hours may be given if a diarrhea begins during the 
course of the disease. 

The heart should be carefully watched, and at signs of heart 
failure stimulants administered for their effect. For a child of 
one year any of the following may be given: strychnia ^^oo to 
Yo^o grain ; tincture of strophanthus one or two minims ; brandy 
twenty to thirty drops, any one. of which may be tolerated well 
by the stomach. 

Care should be exercised not to give nauseous doses in this 
condition, too much depends on the stomach to abuse it. 

In unresolved pneumonia it is most imperative that a change of 
climate be had as soon as possible, to the pine regions or the sea- 



218 THE DISEASES OP CHILDREN. 

side of the South. The child should remain out of doors con- 
stantly and sleep out most of the time. 

Cod liver oil, iron or hypophosphites are valuable agents dur- 
ing convalescence. 

LOBAR PNEUMONIA. 

Synonyms. — Croupous pneumonia, fibrinous pneumonia, lung 
fever. 

Etiology. — An acute primary infectious disease involving an 
entire or a portion of a lobe of the lung, due to an invasion of 
the diplococcus pneumoniae or the pneumococcus of Fi"iedlander. 
It is much more common in children under two years of age 
than is generally thought. Riviere shows in 196 cases during 
the first 15 years that the greatest number occurred at the age of 
two years. Season is a contributing, cause, it being more prev- 
alent in the late winter and spring. Sudden changes in the 
weather and exposure are predisposing causes. 

Pathology. — The process in the lung is practically the same in 
children as in adults; four stages; congestion; the stage of red 
liepitization, in which there is filling up of the air cells and 
smaller bronchi with products of inflammation and peribron- 
chial and interstitial involvement; grey liepitization, with soft- 
ening and loosening of the exudate ; and the stage of resolution, 
in which there is a removal by absorption and expectoration of 
the extravasated mucus, pus and detritus accumulated in the 
bronchi and vesicles. 

Symptomatology. — The onset is sudden in most cases, the child 
becomes suddenly sick without any distinct prodromata, as a rule, 
unless it be vomiting and a rigor. The rigor may not be noticed 
in a young child, save by cold extremities, which may be over- 
looked. With a rise in temperature there may be a distinct 
convulsion, especially in those children who are highly nervous, 
and who usually give a history of convulsive seizures with each 
illness, in which there is a rise in temperature. Convulsions 
are more apt to occur in young children with pneumonia than 
in older ones. 

The temperature rises quickly, being, as a rule, higher than 
in bronchopneumonia, frequently reaching 103° or 104° F. 



DISEASES OF THE RESPIRATORY ORGANS. 



219 



There is an excursion of from 1° to 4° F. between the morning 
and evening records. The respiration is accelerated from the be- 
ginning, frequently being seen as high as 80 or 90 to the minute, 
in fact, this symptom may be the first noticed. With it is the 
characteristic expiratory grunt, and a dilatation of the alae nasi. 




Fig. 49. — Lobar pneumonia; crisis seventh day. 



The pulse is accelerated and the ratio in this form of pneumonia 
between pulse and respiration is greatly disturbed; it may be 
as low as 1^ to 1, though 3 to 1 is more frequent, 150 to 50 
being a frequent record. The cheeks are flushed and often the 
greatest color is noted on the cheek on the same side as the 
affected lung. 

There is usually considerable prostration, the child taking 
but little interest in his surroundings. The urine is scant and 
high colored. Cough is by no means a constant symptom, 
though it is very often present. There is usually no expectora- 
tion even in older children, the mucus dislodged being swallowed ; 
when expectorated it is thick, viscid and often blood-stained. If 



220 THE DISExiSES OF CHILDREN. 

there is an involvement of the pleura over the affected area the 
cough is suppressed as it is very painful, and the breathing is 
chiefly diaphragmatic, and in these cases the expiratory grunt is 
more pronounced. With a pleurisy there is often a fixation of 
the neck and upper extremities, as moving them causes more 
pain. Abdominal pain may be complained of. 

Constipation is the rule in lobar pneumonia, and the opposite 
usually in bronchopneumonia. Anorexia is the rule. 

One of the best signs as to the amount of compensation which 
exists is the color of the skin, lips and lid conjiinctivw. If they 
remain red, in spite of the rapid breathing and evident dyspnea, 
nature is taking care of things. The skin is usually hot and 
dry with no perspiration until after the crisis. 

Termination. — The termination of the disease is usually sud- 
den, by crisis, in from four to seven days. The temperature 
may fall from 103° or 104° F. to normal or subnormal. The 
temperature may show a slight rise after this drop, which is 
usually designated as the postcrisal rise. Some obscure and 
central cases of pneumonia may be of very short duration, the 
crisis occurring as early as the third day. 

Physical Signs. — The pathognomonic sign of the first stage 
of pneumonia, the crepitant rale, is not heard much more fre- 
quently in children than in adults, as the case is usually not 
seen early enough. The first sign noted may be a diminished or 
distant respiratory murmur. Inspection reveals the rapid breath- 
ing, dilatation of the alse nasi and flushed face. 

Second Stage. — Palpation may give increased vocal fremitus 
if the area of consolidation is large enough and near enough to 
the surface. There is dulness on percussion over the consolida- 
tion and an increased resonance over the uninvolved area. The 
dulness may shade off into the resonant area gradually. 

Auscidtation reveals the typical bronchial breathing over the 
affected area. In auscultation over the apices, posteriorly, the 
normal broncho-vesicular breathing of this region must be borne 
in mind. The use of the stethoscope with small bell or chest 
piece is urged as the area of consolidation which is near the sur- 
face may be small. No adventitious sounds may be heard at all, 
but more frequently moist rales are heard on the edges of the 



DISEASES OF THE RESPIRATORY ORGANS. 221 

consolidation, during the first stage, and over all during the third 
stage. 

Care must be taken to differentiate the kind of rale heard and 
its location. Very frequently there is an involvement of the 
pleura over the affected side, in which event the rales are small, 
fine and crackling, and very close under the stethoscope, heard 
most distinctly at the end of inspiration or during coughing. 
With involvement of the pleura there is pain on coughing. 

Over the unaffected portion of the lung there is an exaggera- 
tion of the normal vesicular murmur. 

In the third and fourth stages the bronchial breathing is 
fainter and there are many rales present, the rale redux, much 
like the rale heard in the first stage. 

Resolution may rarely be delayed, most frequently it is prompt 
and complete within a week after the crisis. Auscultation at 
this time often fails to reveal any difference in breath sounds in 
the two sides. 

The most frequent site of the consolidation has been variously 
stated by different observers. Perhaps the left lower lobe is more 
often affected, next the right upper lobe, then the right lower lobe. 
Apical pneumonia is of frequent occurrence, but we believe it is 
a fallacy to expect meningeal complications more frequently in 
apical pneumonias than when other portions of the lung are 
affected. 

The varieties of pneumonia are usually classified according 
to the physical signs and the symptoms. Abortive pneumonia 
is that form in which a crisis occurs within a few hours after the 
initial symptoms, and the lung clears up more slowly; or there 
■ may be no positive signs found in the chest. In typhoid pneu- 
monia the case is- a prolonged one and the general condition 
is like that of a typhoid fever, but without any symptoms of 
typhoid, save the low state of the patient. In relapsing pneu- 
monia, after a short period of remission of symptoms, there is 
an exacerbation due to an involvement of new areas. This in- 
volvement may be of contiguous lung tissue or an area in the 
opposite lung involved. Pleuropneumonia is a condition where 
the involvement of the pleura is severe, either with or without 
extravasation of fluid. 



222 THE DISEASES OF CHILDREN. 

The complications of pneumonia are many and often severe. 
Among these may be mentioned pleurisy with effusion. The 
entire absence of sounds over any area of the lung, especially 
the base, with an increase in the dulness is always a suspicious 
occurrence, and effusion into the pleura should be thought of. 
In these cases the resolution is delayed. Exploratory aspiration 
should be performed in obscure cases. Empyema, otitis media, 
pericarditis, endocarditis, peritonitis may occur. 

Meningitis is a very grave complication. As before stated 
meningeal symptoms are not more frequent in apical pneu- 
monia than when the base is affected. The first evidence of 
meningeal involvement may be an intense headache in those 
children old enough to localize pain, with restlessness. There 
is a rise in temperature, pupillary symptoms, perhaps convul- 
sions, etc. 

Diagnosis in some cases of deep-seated pneumonia is at first 
very difficult, as no physical signs are present to aid. It has 
been suggested ^ that the X-ray illumination of the chest is a 
valuable diagnostic measure. Three forms may be distinguished, 
(1) lobar or fibrinous inflammation, (2) disseminated broncho- 
pneumonic foci, yield no shadow; (3) the so-called central pneu- 
monias, which yield a distinct shadow transillumination. 

The principal condition to be diagnosed from is a hroncho- 
pneumonia, which has been mentioned in previous pages. 

Appendicitis may be suspected from localization of pain in the 
abdomen. Careful examination of the chest clears this up. 

Prognosis is good. It is graver, the younger the child affected, 
but in uncomplicated cases the mortality should not exceed 15 
per cent under two years of age and 5 per cent in children of all 
ages. 

Treatment. — There is no specific for pneumonia, but much 
can be accomplished to alleviate suffering and, I believe, to hasten 
the crisis. 

The patient should be placed in bed at once in as large and 
airy a room as possible and the windows thrown open, no matter 
what the season of the year. Hot-water bags should be kept to 
the hands and feet, and the patient even in winter not too heavily 



1 Weill- Shi venet (Arch, de Med. des Enfants, No. 7, 1907), 



DISEASES OF THE RESPIRATORY ORGANS. 223 

covered. It should wear an undershirt and night shirt or draw- 
ers. Oil-silk jackets, cotton-wadded coats and poultices are not 
necessary, and, I think, positively harmful. 

An initial dose of calomel should be given as soon as the child 
is seen, preferably in the form of a tablet triturate, finely pow- 
dered, to a child of one year a grain ; 2 grains to an older child. 
Castor oil may also be used to advantage. 

For temperature above 104° F. there should be given a sponge 
bath followed by a brisk rub, but for a lower temperature the 
bath need not be given. With an ice bag to the head for tem- 
perature above 103° F., its rise is fref[uently prevented. The 
use of ice applied to the affected side, as advocated by Mays 
of Philadelphia, I have found a very useful measure indeed. 

The screw-cap ice-bag, partly filled with crushed ice, wrapped 
in a towel and applied to the consolidated area, in my experi- 
ence, has lessened pain, lowered temperature and, I believe, 
hastened the crisis in a number of cases. The bag is applied 
and removed in an hour; on an hour, off an hour, being the 
usual rule. 

It may be necessary in cases of severe hyperpyrexia to use 
the cold pack as described on page 80. Antipyretic drugs are 
mentioned only to be condemned. 

Heart stimulants should not be given as soon as a diagnosis 
of pneumonia has been made, as is so frequently done. Wait 
for the indication and give it for that, and withdraw it as soon 
as possible. Brandy is preferable to whisky, and should be pure. 

The diet should be liquid, preferably milk, partly skimmed 
and diluted, or buttermilk to older children. Broths may be 
given if milk is not tolerated well, an occurrence most infre- 
quent. It will probably be taken in small quantity, at three- 
hour intervals. Give all the cool water the child will drink. 

In the presence of pain from pleuritic involvement a mild 
sedative, heroin, in Y^q grain dose, to child of one year, or 
codeine sulphate, % grain dose, may be needed. A mustard 
plaster applied to this area is most beneficial. 

The condition of the pulse and heart's action should be fol- 
lowed closely throughout the attack. If cyanosis is present there 



224 THE DISEASES OF CHILDREN. 

may be a condition of acute dilatation of the right heart, when 
a prompt dose of nitroglycerine followed by digitalin, hypoder- 
mically, may be the turning point toward recovery. 

Strychnia can be given with good effect but should not be 
given without a clear indication for its use. 

The bowels should be closely watched and kept freely open, 
prompt medication given when indicated, or resort had to en- 
emata. 

In the cyanotic cases oxygen is of great benefit and its use 
should not be postponed too long. 

Watchful nursing should be insisted upon after the fourth 
day when the crisis may be expected, and active stimulation used, 
if needed, at this time. 

After the crisis and resolution has progressed satisfactorily, 
the child should be allowed to assume the upright position slowly. 
At this stage the following prescription may advantageously 
be used : 

I^ Ammonise chloridi gr. iv 

Syr. ipecacuhana 3i 

Elix. simplicis ^ss 

Aquse dest. q. s. ad ^^i 

M. ft. Sol. Sig. One teaspoonful. 

Syrup of iodide of iron or syrup of hydriodic acid can be used 
to advantage. 

PLEURISY (PLEURITIS). 

This is either primary or secondary, and may be of a simple 
fibrinous variety, or there may be a serous effusion in the pleural 
cavity. 

Etiology. — It has been said by some observer, "Once a pleurisy 
always a pleurisy," implying that the real cause of a pleurisy 
is the tubercle bacillus, and that every case of pleurisy should 
be looked upon with suspicion. 

It is surprising how frequently, in postmortem work, adhe- 
sions are found between the lung and costal pleura, evidencing 
an old pleurisy, perhaps recognized at the time but afterward 
forgotten. 

Pneumonia, the pneumococcus, being the active causative fac- 
tor ; traumatism ; the exanthemata are frequent causes of pleurisy. 



DISEASES OF THE RESPIRATORY ORGANS. 225 

the streptococcus and staphylococcus being frequently present. 
It is in pleurisy with effusion that the tubercle bacillus is most 
often found. These may have found entrance to the pleura from 
the bronchial lymph nodes, the intestinal tract, the tonsils, or the 
trachea. 

Pathology. — In fibrinous pleurisy there is a plastic exudate 
over the affected area, with cobweb or more dense adhesions if 
the case is an old one. In the sero-fibrinous form, with effusion, 
the fluid when aspirated usually flows freely, is albuminous, clear, 
and of a greenish tinge. If affected with pus-producing organ- 
isms the fluid changes in character to pus, constituting an em- 
pyema. 

Usually but one side is affected, though there may be an effu- 
sion in each cavity. 

If the cavity is full of fluid the lung is compressed and dense 
like liver, sinks in water, and is very dark in color. If the col- 
lection of fluid is in the left pleura there may be marked dis- 
placement of the heart. 

Symptoms. — Pleurisy occurs more frequently in children over 
two years of age. In primary cases, acute in onset, there may 
be a chill, or rigor, pain on breathing, especially when lifted or 
turned in bed or on deep inspirations, soon a hacking, ineffectual 
cough occurs, and there is fever running between 101° F. and 
102° F. though it may be as high as 104° F. Respirations are 
quick and jerky and chiefly diaphragmatic, unless the diaphragm- 
atic pleura is involved. There is great restlessness, and constipa- 
tion is present, and if associated with tympany the breathing is 
further embarrassed. 

In the form in which there is a gradual outpouring of serum, 
the symptoms are not so acute, the temperature lower, and as the 
fluid separates the two inflamed layers of pleura, the pain is less. 

The location of the pain is an important aid in diagnosis, 
and often misleading. It may be referred to the shoulder or 
to the iliac region, when upon the right side being suggestive of 
appendicitis. 

In this kind of case the child may be up and around, but list- 
less and not inclined to play continuously. 

The tongue is furred and the appetite capricious or lost en-' 



226 THE DISEASES OF CHILDREN. 

tirely. In evident tubercular cases the clubbing of the fingers 
is soon noticed. 

Physical Signs. Inspection. — Limited movement of the af- 
fected side is usually apparent in the first stage of both forms. 
Fixation of the chest is present in effusion, with displacement 
of the apex beat of the heart. 

Mensuration with two tapes sewed together at 1 inch will 
show limited expansion of the affected side. 

Percussion. — Only with effusion will there be much change 
in percussion note unless there be a thick fibrinous deposit over 
the pleura, when there will be an impaired resonance, if not 
dulness. Over an effusion there is flatness, an entire absence 
of pulmonary resonance. With a large effusion a line of de- 
marcation cannot be distinctly made out as the pressure on the 
lung and collapse of the bronchi causes a loss of resonance over 
the lung. There is exaggerated pulmonary resonance over the 
unaffected side. 

Palpation. — In pleurisy sicca friction fremitus can be felt. 
The displaced apex beat may often be better felt than located 
by inspection. Over the effusion there is absence of vocal frem- 
itus, with probably an increased fremitus over the compressed 
lung above. 

Auscultation. — If done early in both forms the characteristic 
pleuritic friction sounds are heard, varying from a distinct 
crackle, a sound like pulling two pieces of buttered bread apart 
when held close to the ear, or the sound of creaking leather. 
As soon as effusion takes place these sounds disappear as do all 
breath sounds. There is nothing so eloquent as silence over 
an area of the chest where normal sounds should be heard. A 
high-pitched breathing, due to compressed lung, may be heard 
through a comparatively small layer of fluid. Exaggerated high- 
pitched breathing is heard over the compressed lung, above the 
level of the fluid and over the unaffected lung, due to the com- 
pensatory work done by it. 

Vocal resonance is absent over the effusion but increased over 
the compressed lung. 

Diagnosis. — This is usually easy, especially if the effusion is 
in fairly large quantity. In dry pleurisy there may be some 



DISEASES OF THE RESPIRATORY ORGANS. 227 

doubt as to the exact location of rales heard, whether in the 
finer bronchial tubes or in the pleura, but in connection with 
the other signs the differentiation can usually be made. A dis- 
placement of the apex beat of the heart should make one suspi- 
cious of pleurisy with effusion. 

Prognosis. — The usual duration of an acute attack of dry 
pleurisy is from 4 to 10 days, and they rarely terminate fatally, 
though the side may remain indefinitely crippled from adhe- 
sions. If there is enough effusion to cause a marked displace- 
ment of the heart, a fatal termination may result. The associa- 
tion of tuberculosis with a pleurisy Avith effusion should be borne 
in mind and a guarded prognosis given. 

Treatment. — The patient should be put to bed at once and 
an initial dose of calomel given. If the pain is excessive it 
can be controlled by an opiate, Dover's powder, paregoric, 
heroin or morphine. Such relief can be had also from counter 
irritation b}^ a mustard plaster applied over the site of the pain, 
care being taken not to raise a blister. 

Relief can also be had in some cases by applying an adhesive 
plaster strip as would be applied over a fractured rib, limiting 
the motion of that side. The strip should be applied at the end 
of a deep expiration. 

Aspiration in cases of effusion should be done only in those 
cases in which there is no evidence of absorption at the end of 
two weeks, or where there is great dyspnea or marked displace- 
ment of the heart from left-side effusion. Only a relatively 
small amount of fluid should be withdrawn, the point of selection 
being the interspace about the middle of the area of greatest dul- 
ness, the patient in the upright position if possible, leaning for- 
ward to hold the tissues tense. 

The skin should be most carefully prepared by soap and water 
and alcohol and the needle boiled. The aspirator should be tried 
with the needle in sterile water to be sure that the current of 
suction is not reversed. The upper border of the rib should be 
hugged by the needle to avoid the vessels. No local anesthetic 
is needed, as a rule, though ethyl chloride may be used. 

The iodides are indicated, syr. iodide of iron being most effi- 
cient, in half teaspoonful doses to child of two years. 



228 THE DISEASES OF CHILDREN. 

Nourishing food, plenty of fresh air and a change of climate 
is most beneficial. 

EMPYEMA. 

A collection of pus within the pleural cavity. 

Etiology. — This may be the result of an infection of an ex- 
travasated fluid in a pleurisy, or an original or primary infection 
of the pleura due to the pneumococcus, streptococcus or staphylo- 
coccus. It is very rarely an original infection, being secondary 
to pneumonia in .fully 90 per cent of cases. It may also compli- 
cate diphtheria and the exanthemata, in fact, any infective proc- 
ess may cause it, tonsillitis, pyema, osteomyelitis, etc. It may 
be of traumatic origin. In children the tubercle bacillus is more 
often responsible for pleurisy with effusion than empyema. It 
more often affects children between six months and three years 
of age, although no age is exempt. A large percentage of ef- 
fusions in the pleural cavity in childhood are purulent. 

Pathology. — ^With a large collection of pus as in pleurisy with 
effusion there is a displacement of the heart. There are numer- 
ous adhesions between the two layers of pleura, causing saccula- 
tion. The pus is thick, a very dark yellow, and many lumps may 
be present. This fact must be borne in mind in aspiration, for 
either diagnostic or curative purposes. 

There is an associated unresolved pneumonia, the consolida- 
tion being more of the lobar than the broncho type. If there is 
much fluid there may be a compression of the lung without con- 
solidation. 

An infection of other serous cavities may complicate an 
empyema, a pericarditis, endocarditis, peritonitis or synovitis. 
Bronchopneumonia may arise as a complication, especially if 
there is a rupture of the fluid into the lung. 

Symptoms. — In primary cases the onset is sudden, a chill or 
rigor, usually, with pain and dyspnea, much the same as in a 
pneumonia; a rise of temperature to 103° or 104° F. The fever 
is usually irregular, a morning remission and high in the even- 
ing, followed by a sweat. It must be borne in mind, however, 
that there may be a large accumulation of pus in the cavity and 
a comparatively small rise in temperature. In secondary cases 



DISEASES OF THE RESPIRATORY ORGANS. 229 

there may have been an apparent improvement in the pneu- 
monia followed by a gradual rise in the temperature, and increase 
in all the symptoms, the cause of which may not be clear without 
a careful physical examination. The cough returns and becomes 
c[uite annoying, with no expectoration, there is a progressive loss 
in weight ; some pain in the affected side, especially when taking 
a long breath ; loss of sleep ; no appetite ; restlessness ; constipa- 
tion; anemia and a tendency to clubbing of the fingers. There 
may be a decided interference with respiration, so the child has 
to be held or propped partly up in bed. The dyspnea may not 
be. noticed markedly unless the patient is moved, or turns sud- 
denly in bed. This is specially the case if there is enough effu- 
sion to cause a displacement of the heart and large vessels. 

Physical Signs. — There are no essential differences in the 
signs found in empyema and in pleurisy with effusion, save 
when an empyema complicates a pneumonia, owing to the thick- 
ness of the fluid and its better conducting power, bronchial 
breathing may be heard through it. This bronchial breathing 
is usually more distant and faint than that heard above the 
level of the pus over the compressed lung. The effusion is usu- 
ally at the base, but may be localized at several points owing to 
the possibility of adhesions forming and the fluid becoming 
pocketed. Collections of pus at the apex may occur, but very 
rarely. 

Diagnosis. — The diagnosis is principally from a lobar or 
bronchopneumonia, and pleurisy with effusion. The physical 
signs are to be relied upon principally for a diagnosis. In lobar 
pneumonia the crepitant rale heard early may be mistaken for 
a pleuritic friction sound, but this is rapidly followed by bron- 
chial breathing and dulness, whereby the bronchial breathing, if 
heard at all over the extravasation of fluid, is heard late. There 
is no displacement of the heart in pneumonia, the percussion note 
is flat in empyema. A leucocyte count may assist in the diagnosis 
of an empyema. The polynuclear percentage is high in empyema. 
From pneumonia, as well as pleurisy with effusion, it may re- 
main for an exploratory puncture to clear up the diagnosis. 
This must be done under the strictest aseptic precautions, careful 
sterilization of the needle and preparation of the field and hands. 



230 THE DISEASES OF CHILDREN. 

A needle of sufficient size should be chosen to allow thick pus to 
flow through. The point of election for an exploratory puncture 
is in the sixth interspace in the posterior axillary line. It may 
be necessary to examine a drop of the fluid microscopically to 
definitely determine its nature, as serous pleural effusion is often 
very turbid, resembling pus. 

Prognosis. — This can be said to depend to a great extent upon 
the promptness of diagnosis and the method of treatment em- 
ployed. Age, previous illnesses and cause also influence the 
outcome as well as the presence and nature of complications. 
In cases in which there is a mixed infection the prognosis is not 
so good. Pure pneumococcus infections are more favorable. 

Treatment. — The treatment of empyema is surgical, and three 
methods are in vogue, aspiration, simple incision and rih resec- 
tion. Aspiration should not be resorted to except as a diagnostic 
measure. A large quantity of pus may be withdrawn but its 
tendency is to quickly reform. 

As the indication is quick removal of the pus as soon as rec- 
ognized, the best method of removal is an incision of the inter- 
costal space, with tube drainage afterward until the pus ceases 
to flow. The point to be selected for the incision should be 
carefully made, the object being to have the opening at as de- 
pendent a point as possible, bearing in mind the probable saccu- 
lation of the fluid. 

Usually the seventh or eighth interspace is chosen about the 
posterior axillary line, and the incision made 2 or 2i/2 inches 
long, close to the upper border of the rib, this being advantageous 
in avoiding vessels and nerves, and is more convenient in case 
a rib resection is later necessary. 

With strict aseptic precautions the incision is made under a 
local anesthetic, cocaine or ethylchloride, down to the pleura. 
A general anesthetic is dangerous. The pleura is nicked and 
the opening enlarged with an artery forceps, and a considerable 
quantity of pus allowed to escape. Drainage tubes, previously 
prepared, fenestrated and armed with large safety pins in the 
outer end, are pushed in the cavity, and the remainder of the 
pus allowed to flow out into the dressings, which are immedi- 
ately applied. Gauze, absorbent cotton, waste or oakum, make 



DISEASES OF THE RESPIRATORY ORGANS. 231 

good dressings in tlie after treatment. The first may be used 
wet to facilitate absorption. 

Should the pus be very thick and not flow freely a subperiosteal 
rib resection should be done. This requires a general anesthetic. 
The incision is slightly enlarged, the rib exposed, the periosteum 
elevated, and a section of the rib 1 or 2 inches in length removed 
with bone forceps. A tube is then placed in this opening and 
drainage is much more free. 

The after treatment of the operative cases consists in daily 
or more frequent dressing, removal of the tube each day and 
cutting off from half an inch to an inch and replacing it, until 
by the end of the week it can be removed entirely. 

Irrigation of the pleural cavity should be discouraged always. 

Vaseline or oxide of zinc ointment can be used to advantage 
on the skin around the opening to prevent excoriation. The 
tube had best be pinned to an adhesive plaster strip and this 
applied to the skin to prevent its slipping into the cavity. 

On the removal of the tube for good a small strip of gauze 
should be carried into the opening for a few days to prevent its 
closing too quickly. 

Deformity of the chest, due to failure of the compressed lung 
to properly contract after evacuation of the pus is sometimes 
seen. 

General tonic treatment, fresh air and judicious feeding is of 
importance in the after treatment. 

GANGRENE OF THE LUNG. 

This is a rare condition in children, and may only be recog- 
nized at the autopsy table. 

Etiology. — Some process has been present in the lung pre- 
viously, favoring bacterial invasion, as a pneumonia or empy- 
ema, or as a complication of noma, the exanthemata, suppurative 
tonsillitis or middle-ear trouble. An embolus of septic origin 
may be a cause. 

Pathology. — There may be one or a number of foci of gan- 
grene ; the areas are dark in color and the fluid present is green- 
ish in color and very foul-smelling. There is an area of 
consolidation usually around these gangrenous spots. If near 



232 THE DISEASES OF CHILDREN. 

the surface a pleurisy generally is found, and they may ulcerate 
through into the cavity. 

Symptoms. — These may be obscure, and unless a bronchus be 
invaded by rupture of a gangrenous area and some of the fluid 
expectorated the condition may not be suspected. This fluid 
is dark, thick, contains pus, blood, mucus and lung tissue, and 
is foul smelling. 

If complicating or following a pneumonia, there is an exacer- 
bation of the symptoms, prostration, usually a foul breath, in- 
crease in fever, quite rapid loss of flesh and strength, and sweats. 

Physical Signs. — Unless a gangrenous area has broken down, 
forming a cavity, the signs may not vary from those found in a 
pneumonia. In this even cracked-pot resonance ; amphoric reso- 
nance, and probably gurgles may be found. 

Treatment. — When a diagnosis has been made and the site of 
the trouble located positively, a pneumonotomy is indicated fol- 
lowing a rib resection. Tonic treatment and stimulation should 
be begun early. 



CHAPTER XII. 

DISEASES OF THE DIGESTIVE SYSTEM. 
DISEASES OF THE LIPS. 
Ulcerations at Angle of Mouth. 

Synonym. — Perleche. 

Definition. — This is a form of cracking of the mucous mem- 
brane or ulceration at the angle of the mouth, first described 
by Lemaistre. 

Etiology. — It begins as a small fissure or crack at the corner 
of the mouth, which becomes infected by frequent rubbing and 
touching by the tongue, and remains at this point entirely. It 
is more frequently seen in marasmic and anemic children. 

Symptoms. — The erosions are generally linear in shape, con- 
fined to both corners of the mouth, are slightly elevated with a 
red and indurated base. It is painful if the child opens its 
mouth wide, as when yawning. They may be mistaken for the 
rhagades of syphilis, but no mucous patches are found in the 
mouth in perleche. 

Treatment. — The course of perleche is usually for two or three 
weeks. It can be helped by applying a 5 or 10 per cent solution 
of nitrate of silver direct to the surface, followed by a drying 
powder, as zinc oxide or bismuth. The application of an oint- 
ment to these areas prevents the encrustation over them ; bismuth, 
gr. X, to vaseline, 5i ; 3 per cent resorcin ointment ; benzoinated 
oxide of zinc ; yellow or red oxide of mercury, are efficient. The 
use of the ointment following the silver, in winter, is specially 
desirable. 

DISEASES OF THE TONGUE. 

Epithelial Desquamation. 

This condition is also known as the geographical tongue. There 
is an abrasion or exfoliation of the epithelium in irregular areas 

233 



234 THE DISEASES OF CHILDREN. 

over the surface of the tongue with normal or slightly-coated 
surface between. The areas are slightly elevated, and when 
freely desquamated leave a red base. It occurs frequently in 
bottle-fed infants and causes no discomfort ; as a rule requires 
no treatment other than cleansing washes of boracic acid solu- 
tion. 

DISEASES OF THE MOUTH. 

Bednar's Aphthae. 

Pathology. — This is a symmetrical ulceration, one on each side 
of the median line of the soft palate at its juncture with the hard 
palate. It is most frequently seen in the new-born or infant 
under six months of age. 

Etiology. — It is caused by the finger of the nurse too vigor- 
ously cleansing the mouth, an abrasion of the mucous membrane 
occurring readily at the attachment of the soft to the hard palate, 
bacterial invasion taking place at this site. It may follow thrush. 

Symptoms. — The child probably refuses to nurse or it may 
nurse for a few moments, stop and fret on account of the pain. 
Inspection of the mouth with tongue held down reveals two sym- 
metrical, round ulcers at the point indicated above. They may 
have a greyish surface, slightly elevated, with reddened area at 
its base. 

Nitrate of silver solution, 5 per cent, applied directly to the 
surfaces, once daily, and the mouth in front of these ulcers 
washed after each nursing, usually will cure them in a few days. 

STOMATITIS. 

This may be of the following varieties : Catarrhal, herpetic or 
aphthous and ulcerative. 

The catarrhal variety is caused by irritants ; trauma ; exces- 
sively-hot liquids or food, or secondary to exanthemata. 

There is an intense reddening of the mucous membrane, and 
desquamation of the epithelium and a salivation. 

Symptoms. — There is a sensation of heat and pain in the 
mouth; profuse salivation; child will not nurse; is fretful and 
cries a great deal, may be vomiting; enlargement of glands sub- 



DISEASES OF THE DIGESTIVE SYSTEM. 235 

maxillary and at angle of jaw; sleeps with mouth open. The 
duration in robust children is usually only a few days. 

Treatment. — But little is required. Antiseptic mouth washes ; 
crushed ice. If no food is taken for some days gavage is of 
service. 

HERPETIC OR APHTHOUS STOMATITIS. 

Etiology. — Teething, irritating substances in the mouth, and 
as a complication of gastrointestinal disorders, pneumonia and 
other infectious diseases. 

Pathology. — Small vesicles appear on the mucous membrane 
of the lips and cheek; these may coalesce, forming large ones. 
They are superficial as a rule and associated with more or less 
general hyperemia, especially of the area of mucous membrane 
directly about the bases. 

Symptoms. — The presence of the characteristic vesicles on the 
lips, cheek or palate ; salivation ; difficulty in nursing ; enlarged 
glands. The chief difference is in the appearance of the vesicles. 

Treatment. — Care should be taken in using an antiseptic or 
cleansing wash, not to rub the vesicles so as to leave an abraded 
surface below. Chlorate of potash, 2 or 3 grains, well diluted, 
to a child of two years is of great benefit. If the areas coalesce 
and leave a raw base, nitrate of silver is of service, in a 5 per 
cent solution. Prophylaxis is most important. 

ULCERATIVE STOMATITIS. 

Etiology. — It is of bacterial origin, may follow the exanthe- 
mata, and complicate carious teeth. It is seen in wasting dis- 
eases also. 

Pathology. — An ulceration which usually begins at the base 
of a tooth and spreads over the gum to the mucous membrane of 
the lips and cheeks. The ulcers usually have a whitish, depressed 
surface with red edges. There may be deep ulceration at roots of 
teeth causing them to loosen and fall out. 

Symptoms. — Pain when chewing is attempted, excessive flow 
of saliva, fetid breath, tongue thickly coated, ulcers bleed freely 
if touched, sordes on teeth, child is fretful, cries a great deal 
and sleeps poorly. There may be a slight rise of temperature. 



236 THE DISEASES OF CHILDREN. 

The neighboring" lymphatic glands are usually enlarged. The 
gangrenous form may supervene. 

Treatment. — Weak peroxide of hydrogen solution 25 per cent 
followed by an antiseptic wash; saturated boracic acid solution, 
full strength, Dobell's solution, or solution made from Seller's 
tablets. The internal administration of potassium chlorate is 
almost a specific, and should be given in 2 or 3 grain doses to 
a child of two years every 3 or 4 hours. The local application of 
nitrate of silver solution, 10 per cent, to the base of the ulcers 
is of service. 

GANGRENOUS STOMATITIS. 

Synonyms. — Noma; cancarem oris; gangrene of clieek; 
Wangenhrand. 

This is a sloughing or gangrenous process involving the 
mucous membrane and tissues of the cheek, as a rule, though 
it may spread to the gums and lips. Sufficient tissue may be 
involved to have a perforation of the cheek. Both sides of the 
mouth may be simultaneously affected. It usually occurs be- 
tween two and six years of age. 

Etiology. — No specific organism has been satisfactorily iso- 
lated in these cases, though two Russian observers claim to 
have isolated a small bacillus and produced the same conditions 
in guinea-pigs. The diphtheria bacillus, strepto- and staphylo- 
cocci, have been found. Noma occurs after, the exanthemata, 
and diphtheria, after any wasting or prolonged disease in which 
resistance is low, and may start from a severe ulcerative 
stomatitis. It may be epidemic in institutions. 

Pathology. — The starting point is usually on the gum near the 
teeth, and this quickly spreads to the mucous membrane of the 
cheek. The area involved is more or less symmetrically round, 
and at first can be felt as a small, hardened mass which soon 
breaks down, leaving a dark, angry-looking area, bathed in pus, 
and from which a foul odor emanates. In some favorable 
cases a mass of tissue separates and falls out, leaving an excava- 
tion covered with granulation tissue. 

Symptoms. — At first there are few general symptoms, but soon 
there is fever to 103° or 104° F. ; great restlessness; pain; in- 



DISEASES OF THE DIGESTIVE SYSTEM. 237 

ability to chew or swallow; fetid breath, which is noticeable as 
scon as the room is entered; the cheek is much swollen and 
indurated, the edema spreading to the upper and lower eye- 
lids; the skin of the cheek assumes a dusky, dull red color. 
The neighboring glands quickly enlarge. 

In a few hours the slough has extended, and in one to five 
days unless the process is arrested, the cheek will probably be 
perforated. At the same time the gangrene may extend to the 
lower or upper jaw, involving the bone and causing the teeth 
to loosen and drop out. There is a septic diarrhea, and at this 
stage great prostration with rapid and feeble pulse. 

Prognosis. — The prognosis is grave, fully 75 per cent suc- 
cumb in spite of treatment. The duration is from one to three 
weeks, and death ensues from either toxemia or broncho- 
pneumonia. Usually severe deformities of the face remain. 

Treatment. — Attention should always be given to stomatitis 
of any form, especially the ulcerative variety, to prevent the 
engTafting of a cancarem oris upon it. As soon as the diagnosis 
has been made, under a general anesthesia, the area involved 
should be thoroughly cleansed and cauterized with the fine tip 
of a Paquelin cautery, and the cauterization should extend be- 
yond the diseased area. I have had one case recover treated in 
this manner without perforation of the cheek, but ulceration 
extending very close to the skin. 

In this case an examination of scrapings from the ulcer re- 
vealed no organisms except the pus-producing ones. 

Loose teeth and spiculag of bone should be removed. 

The diseased area should be touched each day with a 20 per 
cent nitrate of silver solution, and a cleansing antiseptic mouth- 
wash used. 

It is wise to have a culture made from scrapings from the 
mass, and the diphtheria bacillus looked for. If isolated, the 
child should be given a dose of diphtheria antitoxin at once. 

Active supportive and stimulating treatment must be used, 
such concentrated nourishment as beef juice and broth, pep- 
tonized milk, egg-nogg, etc. 



238 THE DISEASES OF CHILDREN. 

THRUSH. 

Synonyms. — Sprue, mugiiet, soor, parasitic stomatitis. 

This is an affection of the mucous membrane due to the growth 
upon it of a specific organism, the saccharomyces albicans. 

Etiology. — The saccharomyces albicans and not the oidium 
albicans is the cause of the condition. Examination of the 
deposit shows the white threads or mycelium and the small, 
oval bodies, the spores. It is usually limited to the mucous 
membrane of the mouth, but may spread to the larynx, esoph- 
agus and stomach. The organism is carried to the mouth, either 
upon the ordinary nursing paraphernalia or the rubber nipple 
("persuader" or "comforter") toys, sugar-teats, etc. Poorly 
nourished children are prone to develop it. 

Symptoms. — Upon the tongue, gums and mucous membrane 
of the lips, later of the cheeks, there is a white deposit varying 
in size from a pin point to an area the size of the little finger 
nail, the larger masses resembling a mass of curds. Patches 
may be found here and there, or may be very numerous. There 
is apt to be a coincident gastrointestinal involvement, and the 
whole area of buccal mucous membrane is hot, red and dry. 
The child refuses to .nurse, or if older its bottle or ordinary 
food is pushed aside. 

This condition is due, as a rule, to neglect or to over-zealous 
cleansing of the mouth, resulting in an abrasion in which be- 
comes engrafted the infective organism. 

Treatment. — The best treatment is prophylaxis. It can be 
prevented by careful attention to details of cleanliness, of both 
baby and nursing paraphernalia and breasts and nipples of 
mother. Nursing infants are less apt to develop sprue than 
older ones. The occurrence of sprue is usually an indication 
that the nurse or person in charge is careless about the toilet 
of the mouth before and after nursing, and of the bottles and 
nipples. 

Saturated solution of boracic acid is an efficient remedy and 
preventive as well. The finger wrapped in absorbent cotton 
is wet with the boracic acid solution and the deposit gently 
removed. 

This must be done very gently at all times, as the mucous 



DISEASES OP THE DIGESTIVE SYSTEM. 239 

membrane is very easily abraded. The cotton is best changed 
as one part is cleansed. If an aphthous or ulcerated spot is 
found it should be touched with a nitrate of silver solution. 
A cure is generally had at the end of a week or so. 

GONORRHEAL INFECTION OF THE MOUTH. 

This is generally associated with an acute infection in the 
mother of a similar nature, urethral, vulvovaginal, conjunctival, 
and is due to the specific organism, the gonococcus of Neisser 
being transferred to the child's mouth. There must first be a 
trauma, not necessarily macroscopic in size. It occurs usually 
before the child is two weeks old. Fortunately this is a rare 
infection, but few cases having been reported. 

Symptoms. — These may be- very few, and it is entirely pos- 
sible for the condition to go entirely unrecognized. It may 
become engrafted upon a Bednar's aphthge or an abrasion of 
the mucous membrane due to cleansing the mouth. The swelling 
and appearance of the mucous membrane is like that seen in 
catarrhal stomatitis, and to be recognized scrapings from the 
mucous membrane must be examined microscopically. There 
is but little discharge. It usually runs a short course. 

Treatment. — Cleanliness, frequent washing with boracic acid 
solution, and twice daily swabbing out the entire buccal mucous 
membrane, especially under the tongue and lips and gums with 
a 2 per cent nitrate of silver solution, or the same strength solu- 
tion of protargol. 

Care must be taken to protect the eyes and thumb-sucking 
must be prevented. 

SYPHILITIC STOMATITIS. 

When snuffles in a new-born child is seen the mouth should 
be carefully searched for possible mucous patches. 

Any case in which ulcers are found upon the buccal mucous 
membrane should be looked upon with suspicion. 

Typical mucous patches are not as deep as the ulcers of non- 
specific ulcerative stomatitis, are usually upon the lips or mu- 
cous membrane of cheeks, and more rareh^ on the gums. They 
have a dull, white base and may be bathed in a thin pus seere- 



240 TH^ DISEASES OP CHILDREN. 

tion. They may be associated with fissures at the corners of 
the mouth. 

Local application of a mild antiseptic wash, with vigorous 
antisyphilitic treatment is indicated. 

RANULA. 

This is a cystic formation under the tongue, on either side of 
the frenumj and is due to an occlusion of one of the salivary 
ducts or a duct from one of the mucous glands, a Bland-Nuhn 
or Rivinian Gland. There may be a lodgement of a small cal- 
culus in the duct, closing it. 

Symptoms. — ^When the tongue is raised a small, soft, fluctu- 
ating tumor is found under the tongue. The calculus may be 
felt if present. These may be of such size as to interfere with 
nursing and with swallowing, even with the closure of the 
mouth. 

Treatment. — Incision of the cysts, the child being held on 
the nurse's lap, head between physician's knees, who sits facing 
the nurse. The tongue can be held out of the way by means 
of the handle of a grooved director. 

Saliva or a viscid mucus may escape on incision of the cyst. 

TONGUE-TIE. 

Every new-born baby's mouth should be examined, and the 
frenum of the tongue especially inspected. If a baby cannot 
protrude its tongue between or at least to its lips, the frenum 
is too short, the tip folding on itself, making it difficult to form 
a vacuum and the nursing is interfered with. This is seen com- 
paratively infrequently, and when clipped causes great relief. 

Treatment. — The child is held as described in the treatment 
of ranula, and the tongue held by the handle end of a grooved 
director, the frenum projecting through the slit in this. It is 
then cut with a pair of blunt-pointed scissors which have been 
previously set so as to make the cut of prescribed depth, and if 
this does not liberate the tongue sufficiently it is torn by the 
finger as needed. The bleeding is usually very slight. 

RIGA'S DISEASE. 

This condition, described by Dr. Guiseppe,^ occurs more 



1 Gazz. Degli ospedali-dello clin., No. 153, 1907. 



DISEASES OF THE DIGESTIVE SYSTEM. 241 

frequently in Southern Italy, and is mentioned because of its 
likeness to more benign conditions occurring in this country 
just described. It was first exhaustively studied by Riga in 
1880. It does not occur epidemically. The etiology is very 
obscure. 

Symptoms. — It usually occurs in vigorous and previously 
healthy children during the first six months of life. An ulcer 
or gTanuloma forms at the side of the frenum of the tongTie, 
dirty gray in color. The child falls suddenly ill with the ap- 
pearance of the ulcer, suffers with severe collapse and soon 
dies. 

The treatment is of no avail. 

ALVEOLAR ABSCESS. 

This is an infection of the gum or the alveolar process, orig- 
inating usually in a tooth. The conditions may result in an 
abscess which w411 discharge within the mouth, but it is not 
at all uncommon for them to open externally, through the cheek, 
at the angle of the jaw or below the chin. 

Symptoms. — Usually there is a period during which the child 
complains of toothache, and an examination of the mouth may 
reveal a cavity which is filled with food particles. After the 
subsidence of the pain the swelling begins and this is apt to be 
painless, or nearly so. 

The swelling is firm and tense with some redness of the skin. 
The mucous membrane of the affected side is edematous. Pus 
usually is found and frequently can be pressed out from the 
gum along the tooth. 

Treatment. — Much more care should be given the teeth of 
children than is usually the case. Too frequently their cleans- 
ing is left entirely to the child and not supervised, food collects 
and an infected gum results. Children should be taken to a 
dentist at least twice a year, the teeth carefully inspected, and 
attention given those which show signs of softening or breaking 
down. 

When an abscess forms it should not be allowed to rupture 
outside but opened on the inside of the mouth. It should then 
be treated as any other abscess and free dainage maintained. 



242 THE DISEASES OP CHILDREN. 

Regular inspection of the mouths of school children should be 
insisted upon by all school boards. 

FISTULA OF NECK (BRANCHIAL FISTULA). 

A branchial fistula is a congenital failure of the second and 
third branchial clefts to close. An opening persists in the neck 
ending at the inner side of the sternocleido mastoid muscle, 
near the sternoclavicular joint. One or both sides may be 
affected ; if one, it is usually the left. 

The tract may end in a blind pouch but usually leads in a 
more or less straight course to the esophagus or pharynx. If 
the external opening closes a cyst usually forms rapidly, it being 
called a hranchial cyst. The contents of these cysts vary, in 
different cases. They may contain mucus, serum, serum and 
blood and epithelium. 

Treatment. — The treatment of both conditions is entirely 
surgical. 

ACUTE ESOPHAGITIS. 

An acute inflammation of the esophagus which usually is 
caused by the passage of a foreign body, the swallowing of a 
caustic as a lye solution or acid, or ammonia. It may follow 
an acute inflammation of the mouth and pharynx, as in diph- 
theria or thrush. 

Symptoms. — The severity of the symptoms depends entirely 
upon the strength of the irritating substance swallowed and 
the severity of the inflammation, if it is an extension from 
above. In all cases there is great and continuous pain, dys- 
phagia, retching, perhaps vomiting, which greatly increases the 
pain. 

The vomitus may contain pus and usually some blood. There 
is a greatly increased flow of saliva. Restlessness is a marked 
symptom. 

There is a swelling of the mucous membrane of the mouth 
and pharynx, and if this is very great there may be considerable 
dyspnea following the swallowing of the irritant. 

The sequel in these cases which is most to be feared is a 
stricture of the esophagus. A spasmodic stricture may appear 



. DISEASES OF THE DIGESTIVE SYSTEM. 243 

as early as the second day, the cicatricial stricture at a later 
date, after a week or two, or it may be delayed several weeks. 

Treatment. — The treatment of the cases after the injury is 
medical. Morphia or codeine in appropriate dosage to control' 
the muscular spasm and pain ; hj^podermic stimulation is needed ; 
no food or water by the mouth ; sustain the child by nutrient 
enemata ; cold applications externally to neck. As soon as it is 
certain that an esophageal stricture is present, evidenced by a 
muscular spasm on swallowing and regurgitation at once, or 
•entire inability to swallow solid food and difficulty in swallowing 
licpiids; under a general anesthetic chloroform or gas and oxy- 
gen, the esophagus should be carefully explored by esophageal 
bougies, olive-tipped, to locate the number and location of the 
strictures. Makenzie has stated the distance in a child of about 
two years from the gums to the cardiac orifice to be about 7 
inches. The location of the strictures accomplished, their size 
should be ascertained by passage of progressively larger bougies, 
and this repeated at intervals of three or four days. 

With an impassable stricture the case becomes surgical and 
mav eventuate in a g-astrotomv. 



STENOSIS OF THE PYLORUS. 

Pathology. — Our knowledge of pyloric stenosis is directly the 
result of postmortem investigations. A pyloric tumor is almost 
uniformly found about the size of the end of the thumb. It is 
free from adhesions, oval in shape, firm, hard and smooth. It 
is located at the pylorus and when present makes easj^ the loca- 
tion of the pylorus, which is difficult ordinarily. 

Microscopically there is found a hyperplasia of the circular 
muscular fibers, and a very great hypertrophy of the folds of the 
mucous membrane, which lie longitudinally. Secondary changes 
occur in the stomach, namely a dilatation and thinning of its 
walls, which are covered with a thick mucus. 

Symptoms. — The child is apparently normal when born. No 
symptoms are present, as a rule, until the third or fourth day, 
when the first noticed will probably be vomiting. There is a 
disinclination to nurse. The vomiting may be delayed as late 



244 THE DISEASES OP CHILDREN. 

as the end of the second week. The vomiting is characteristic, 
being expulsive, violent and persistent. One or two nursings 
may be retained, and then the total swallowed is violently 
ejected. The child is nearly always restless and uncomfortable 
after nursing and apparently relieved only by vomiting. No 
nausea is present. 

Examination of the vomitus may show free hydrochloric acid, 
but it is not increased in amount; usually there is no bile 
present, no blood or lactic acid. 

There is obstinate constipation, and what is passed for a 
number of days continues to be like meconium in appearance. 

The child instead of gaining its second week continues to 
lose in weight. The temperature is below normal and the pulse 
fast, out of proportion. 

Examination of the abdomen may reveal a fairly character- 
istic condition ; a distension of the abdomen above the umbilicus, 
and a wave of peristalsis may be seen moving from left to right. 
This is best seen in a good light after a feeding. Below the 
umbilicus the abdomen is collapsed and concave. Palpation 
may reveal a pyloric tumor one-half inch to the right and three- 
fourths of an inch above the umbilicus. 

The tongue is clean and the breath normal. 

Diagnosis is principally from gastric indigestion and pyloric 
spasm. In the first the vomiting does not occur as regularly, 
and the amount vomited is not so large or as expulsive as in 
stenosis. The bowels, after a few days of gastric indigestion, are 
apt to be loose and contain mucus, and the loss in weight is not 
so rapid. No peristaltic wave is seen in indigestion. In pyloric 
spasm, the symptoms are essentially the same, but there is no 
tumor present except in hypertrophic stenosis. 

Prognosis. — This depends entirely upon the early recognition 
of the condition and the promptness of surgical intervention. 
The mortality following operation is high. Of 135 cases col- 
lected by Scudder^ the mortality was 48.8 per cent. He esti- 
mates the mortality of medically-treated cases as between 80 
and 90 per cent. 

Treatment. — This is essentially surgical. An operation should 



^Scudder: Canadian Practitioner, August, 1908, p. 95. 



DISEASES OF THE DIGESTIVE SYSTEM. 245 

be performed iramediately the diagnosis is made. Scudder 
mentions three operations: The Loreta operation, consisting 
in opening the stomach and stretching the pylorus by a pair 
of forceps introduced through this opening. Second, pyloro- 
plasty and incision from the stomach into the duodenum, across 
the pyloric tumor, and suturing this incision so as to increase 
the lumen of the pylorus. Both these methods he discredits as 
dangerous and unsatisfactory. Posterior gastroenterostomy is 
recommended after the Mayo method. Several times before the 
operation it is advised to give an enema of brandy and salt solu- 
tion. Stomach washing just before the operation. Arms and 
legs confined to body with separate sheets. Median incision to 
left of umbilicus. Layer suture of wall after operation will 
lessen possibility of hernia. 

The after treatment is important, the Fowler position; very 
careful feeding of whey or barley water or breast milk diluted, 
10 or 12 hours after the operation, first, a teaspoonful, grad- 
ually increased to a tablespoonful every three hours. Breast 
milk should be substituted as soon as possible. 

Vomiting may occur two or three times a day after the opera- 
tion, but gradually subsides. 

DISEASES OF THE STOMACH AND INTESTINES. 

General Considerations. — The digestion of infants and children 
is essentially different from an adult. The new-born infant's 
stomach is a dilated end of the esophagus, without much shape, 
but it quickly assumes, however, the shape of the adult stomach. 
Saliva is secreted in very small quantities until after the erup- 
tion of the deciduous teeth. The stomach of the infant fed upon 
mother 's milk should empty itself in two hours, a slightly longer 
period being taken in the stomach preparation of cow's milk 
for digestion and absorption. At rest the stomach contains 
mucus and but little acid, in the presence of milk, hydrochloric 
acid is secreted. Lactic acid is found occasionally, not always. 
Free hydrochloric acid is not found immediately after a nursing, 
but in from one to two hours following. 

The principal duty of the stomach in digestion is the precipi- 
tation of the casein, the proteid in mother's milk coagulating 



246 THE DISEASES OF CHILDREN. 

in small flocculi, that of cow 's milk in larger masses. The rennet 
ferment or labferment is the coagulating agent. From the 
stomach the contents pass into the duodenum where digestion 
proceeds, aided by the pancreatic juices. Here the carbo- 
hydrates, peptones and fats are digested and absorbed, the pan- 
creatic ferments being trypsin, steapsin and ptyalin. The bile 
aids in the emulsifying of the fats. The digestion of fat is a 
problem which is as yet not fully understood, but it is a fact 
that fat causes much more trouble than is usually believed. 

The bacteria of the stomach and intestines are not fully inves- 
tigated, especially of the former. The principal bacteria which 
may be found in the stomach are the hacterium lactis cerogenes, 
hacillus coli communis^ sarcini ventricidi, the hay 'bacillus, 
and other non-pathogenic organisms. 

The Shiga bacillus, belonging to colon typhoid group, has 
been found in the intestinal discharges in certain cases of diar- 
rhea, especially in those in which the discharge of mucus and 
blood is present. Further study may reveal much of the life 
history of this organism, both in and out of the intestinal tract. 
Among the others most frequently found are the bacillus coli 
communis, streptococci, staphylococci, the bacillus lactis cero- 
genes and the bacillus subtilis. 

The number of stools in the 24 hours varies greatly in differ- 
ent babies, the character, consistence and color of the passage 
being an indication of whether a comparatively large number 
is within the range of normal. The nursing infant during the 
first few weeks may have from three to four movements in the 
24 hours, after this period they are less frequent, but at least 
one passage should be had in 24 hours, and under no condition 
should this be varied from. 

The number and character of the bacteria in milk bear a 
certain relation to this phase of the subject. It is well known 
that ordinary market milk contains from 300,000 to several 
million bacteria to the cubic centimeter, and it has been re- 
peatedly shown that such milk fed to infants results directly 
in serious digestive disturbances and frequently in severe toxic 
and inflammatory conditions of the stomach and intestines. 



DISEASES OF THE DIGESTIVE SYSTEM. 247 

The Feces. — The feces of the new-born are thick, black, tarry- 
like and tenacious, called meconium. These characteristic move- 
ments give way to the normal stool of the infant. These are 
yellow, smooth, consistent and mush-like, as soon as the moth- 
er's milk is secreted or when milk is fed artificially, the black 
color being gradually replaced by the yellow toward the third 
or fourth day. The mother's milk varies so in its analysis at 
different times of the day and night that the infant's stools may 
vary greatly in 24 hours. They may vary from a bright yellow 
to a decided greenish color, and may contain minute or larger- 
sized masses, whitish in color. 

These masses may be composed entirely of casein, in w^hich 
case they are firm and hard, or of fat, when they are soft and 
smooth. If they are fat masses they may have a casein center 
or bacteria may form the nucleus. The recognition of the char- 
acter of the ''curd" in a movement is of importance in arti- 
ficially-fed infants. The stools of artificially-fed infants, as a 
rule, are larger in amount and lighter in color. The effect of 
carbohydrate diluent in milk is shown in the stools by the curds 
being softer and smaller than when water is used as the diluent. 

Thin, yellow, acid movement, containing fine white, curd like 
masses which are soft and easily spread when pressed upon — too 
much fat. 

Large, bean-like, firm masses, with discolored, shiny capsule — 
casein in excess. 

Mucus, thick and tenacious, in large quantities — inflammation 
of sigmoid or colon. When green discoloration is present with 
acid reaction of stool there is serious disagreement of the food. 

Foamy, acid stool — too much sugar. 

The reaction of the infant's stools fed on breast milk is usually 
acid, when fed on cow 's milk is either neutral or alkaline. 

The odor of the normal breast-fed infant's stool is acid, while 
that of the artificially fed has the odor of decomposition. This 
is especially so when animal broths are ingested. 

The bacterial flora of the infant's intestine has been the sub- 
ject of interesting study by a number of observers, but is of no 
clinical value as yet. 



248 THE DISEASES OF CHILDREN. 

GASTRIC DISORDERS. 

Disorders of the stomach may be functional or organic or 
reflex. One of the principal symptoms of disorders of the 
stomach is vomiting. The natural position, shape and size of 
the infant's stomach makes vomiting very easy. It may be only 
a regurgitation of the food as it has been ingested, or the entire 
contents may be expelled, occurring at different periods after 
feeding. Among the causes are too-rapid feeding, impure milk 
in the artificially fed, changes in the mother's milk from various 
causes, pyloric or intestinal obstruction, ulceration of the stom- 
ach, cyclic, recurrent or periodic vomiting, and that caused by 
the acute infectious and exanthematous diseases. 

ACUTE GASTRIC INDIGESTION. 

Synonyms. — Acute gastric catarrh. Acute dyspepsia. 

Acute gastritis, that caused by the swallowing of caustic or 
corroding substances, is rarely seen in infants, and its symptoma- 
tology is practically that of acute indigestion. 

Etiology. — The most frequent causes of an acute indigestion 
are irregular and over feeding. Changes in the character of 
the milk may cause it ; as a single cow 's-milk feeding substituted 
for a breast feeding; changes in character of the breast milk 
from nervous excitement, fear, anger, etc. ; over indulgence in 
older children at children's parties; pastries; hurried eating 
and improper mastication, as is the case when carious teeth are 
present; sudden changes in temperature; violent exercise after 
eating ; too early bathing after a meal, etc. 

Predisposing causes are a prolongation of any one of the 
active causes mentioned, as irregular feeding and eating between 
meals, frequent indulgence in sweets and any condition which 
lowers vitality. 

Pathology. — No specific lesions are present, the condition 
being functional, an arrest of secretion most likely, as well as 
muscular action. 

Symptoms. — The first symptom may be languor and lassitude ; 
the child, if older, will lie down in preference to playing, and 
if old enough may complain of headache. Pain referred high up 
in the abdomen may be present, followed by nausea, vomiting 



DISEASES OF THE DIGESTIVE SYSTEM. 249 

and retching. The vomited matter shows food as it was swal- 
lowed, perhaps some hours before, and is apt to be sour. 

There is always a rise in temperature, it may be slight, but is 
usually between 102° and 104° F. ; the pulse is rapid, with 
slight increase in the number of respirations. There is much 
prostration, languor and deep sleep after the cessation of the 
vomiting. I have seen repeated convulsions until the stomach 
was completely emptied. I recall one child which had a number 
of severe general convulsions at intervals for several hours, which 
ceased only after the stomach was entirely cleared out. The 
movements are apt to be abnormal, containing undigested food 
and showing signs of fermentation, are frequent, and accom- 
panied with gas and straining. The nausea may continue some 
hours after the cessation of the active vomiting. 

Prognosis. — This is usually good as soon as the stomach and 
intestines are thoroughly cleared out of all undigested and irri- 
tating substances. In neglected cases, or those fed too soon 
after an attack, there develops a severe condition of the bowel 
which may result fatally. The younger the child the more 
severe the toxemia. 

Diagnosis. — This is not always easy. It may be difficult to 
rule out the beginning of one of the exanthemata, which may 
be determined only by the appearance of the rash, or a pneu- 
monia, by the development of the pathognomonic physical signs. 

Treatment. — The first indication is to empty the stomach. In 
an older child this may be facilitated by causing it to swallow 
a glass or so of water, cool or warm, this being ejected at once 
brings with it much offending material. If this is not possible 
the stomach should be washed. This is accomplished by a soft 
rubber catheter, No. 16, American, which is attached to rubber 
tube by a glass tube, with a funnel at the free end. The 
catheter is passed into the stomach, the child being held in the 
upright position or lying upon its left side upon an attendant's 
lap. In Oder to control its hands it should first be enveloped 
in a sheet. With the catheter in the stomach, warm w^ater not 
over 100° F. is poured in the funnel, it is then lowered and the 
stomach contents siphoned out, this process being repeated a 
number of times until the wash water returns clear. 



250 THE DISEASES OF CHILDREN. 

Plain, boiled water is best though a solution of bicarbonate of 
soda can be used if the vomitus is very acid smelling. 

After the water has been returned clear for two or three si- 
phonages, from 2 to 3 ounces of water are poured in the stomach, 
the tube tightly pinched between the fingers and quickly with- 
drawn. Pinching of the tube prevents any drops from escaping 
into the larynx as the tip of the tube slips over it. This water 
is nearly always retained and allays thirst. 

The stomach should have absolute rest for three or four hours 
after lavage, and for the first 12 hours, at least, nothing but 
water given by the mouth. After the lavage calomel should be 
given, 1 grain at one dose for a child of six months, 1 grain to 
a child of one year. One grain of calomel for each year of age 
up to five years, 5 grains, can be given with the greatest benefit 
in these cases. 

Even in breast-fed infants nursing should be resumed most 
carefully. The breast should be emptied regularly and the milk 
thrown away until nursing can be begun. In the artificially 
fed, milk should be returned to more slowly. 

When all nausea has ceased and the movements are improved 
give dextrinized barley water, then whey and barley water or 
one of the animal broths, plain or with barley water ; albumen 
water, if there is not a great deal of gas. Care should be exer- 
cised in the amount of food which is given at a feeding, at first 
1 or 2 teaspoonfuls, then i an ounce, and, finally, the usual 
quantity taken by the child. 

But little medication is called for in these cases other than 
the calomel. Good results are often had from cerii oxalatis, 2 
grains every two or three hours, where the nausea persists after 
the cessation of the vomiting. 

Should constipation follow the active symptoms, the bowels 
are best controlled by the use of enemata or glycerine supposi- 
tories, rather than by the administration of laxatives or purga- 
tives, which may cause nausea or vomiting again. 

Hydrotherapy should be used to control the temperature. 

Rest in bed is most essential and the child should not be held 
or coddled. 



DISEASES OF THE DIGESTIVE SYSTEM. 251 

ACUTE GASTRITIS. 

Etiology. — Any of the causes of acute gastric indigestion, if 
prolonged, may cause this condition, or if the child is in a par- 
ticularly run-down condition an acute catarrh may result in 
an acute gastritis. It may complicate the exanthemata, influ- 
enza, diphtheria or pneumonia, and is frequently secondary to 
acute inflammatory conditions of the intestinal tract. The in- 
gestion of any of the caustic irritants will cause it. 

Pathology. — The stomach may be found contracted or dilated, 
usually the former, the mucous membrane is congested, thick- 
ened, softened and covered with a thick mucus, with more or 
less food free in its cavity. Macroscopically but little can be 
detected, a small hemorrhagic area may be seen. Microscopic- 
ally the inflammation is seen to be mostly tubular, the epithelium 
is shed. 

If the inflammation is due to the swallowing of caustic poi- 
sons there are areas of ulceration, the congestion is much more 
intense and the mucous membrane more swollen. 

Symptoms. — The onset is similar to that of gastric indigestion, 
pain, vomiting and fever. The vomitus at first is food, then 
mucus, which may be blood-tinged, there is diarrhea during the 
acute stage, followed later by constipation. The temperature 
is not as high as in indigestion and gradually disappears as the 
disease progresses toward a favorable termination. The dura- 
tion of the attack is from five to seven days. 

Prognosis. — In the robust the prognosis is good, in the weak 
and athreptic it is not so favorable. The danger in the form 
due to the ingestion of caustic substances is in a stricture of the 
cardiac orifice of the stomach. It may result in a chronic gas- 
tritis or severe inflammatory conditions of the intestines. 

Treatment. — The early treatment is practically that of an 
acute indigestion, rest in bed, evacuation of the stomach, even 
if resort must be had to the stomach tube. The stomach washing 
can be repeated daily or oftener, if necessary, and starvation. 

The physician must have entire control of the diet of the 
patient. Proper food must be given, and this means properly 
selected, prepared and administered, and at the proper intervals. 



252 THE DISEASES OF CHILDREN. 

Dextrinized barley water should be first given, and if tol- 
erated, in a few feedings some milk, in very small quantities, 
can be added to it, preferably centrifugal skim milk which con- 
tains much less than 1 per cent of fat. Buttermilk will fre- 
quently be tolerated when whole or skimmed cow 's milk will not. 

Hydrotherapy should be used exclusively for high tempera- 
ture. If there is much thirst and the vomiting continues, a 
high saline enema will prove of service. 

Bismuth in large doses, 60 grains in the 24 hours, is a valu- 
able agent in this condition. 

1$. Bismuth subnitrat 3iiss 

Syr. rhei aromat 3i 

Aquge dest. q.s. ad ^ii 

M. (Shake.) Sig: One teaspoonful. 
A daily or twice daily bath should be given; when there is a 
rise in temperature, it can be used oftener. 

CHRONIC GASTRITIS. 

A chronic inflammatory condition of the stomach, occurring 
independently or with a similar condition in the bowels. There 
may be but slight change in the mucous membrane, the symp- 
toms being from the functional disturbances present. 

Etiology. — A single attack of acute gastritis, or prolonged 
attacks may result in the chronic form. It is much more apt 
to occur in hospital infants and those who are run down from 
any cause, and in those who live in squalor and unhygienic sur- 
roundings. Any of the diseases of nutrition, as rachitis, tuber- 
culosis, anemia, are direct predisposing causes. Improper food, 
bananas, tea and coffee, pastries and sweets, may act as a cause. 

Pathology. — The mucous membrane is thickened and shed 
largely of its epithelium; there is much more mucous on the 
surface of the membrane than in the acute form, and frequent 
lavage is often needed before the stomach is entirely rid of it. 
It is so tenacious that a large quantity of water may be needed to 
entirely remove it. The stomach wall is thickened and the 
stomach itself distended. The solitary follicles are enlarged. 

Symptoms. — Frequent vomiting without apparent cause is 



DISEASES OF THE DIGESTIVE SYSTEM. 253 

the most regular symptom, and often undigested food is vom- 
ited several hours after it is eaten. 

This is due to the interference with the motor function of 
the stomach walls from the inflammation and the distension, and 
to the perverted stomach juices. 

There are frequent attacks of colic; coated tongue, rapid loss 
in weight ; sour breath, the muscles are flabby ; the skin assumes 
a yellowish color; the bowels are constipated at first, followed 
by diarrhea ; there is a loss of appetite ; loss of sleep and rest- 
lessness; circulation is poor, and extremities cold. The child 
may live for a long while, wasting rapidly and die suddenly 
at the end, when death has hardly been expected. 

Prognosis. — In general this is not good, unless the physician 
has constant and direct control of the diet, hygiene and life of 
the child. Intestinal involvement influences the prognosis badly. 
Recovery is slow. 

Diagnosis. — The principal condition to be borne in mind 
is that of pyloric stenosis, considered in another place (see page 
243 ) . Chronic gastritis is not apt to occur in the newly-born, in 
whom pyloric stenosis is most often seen. 

Treatment. — As already stated the physician must be in con- 
trol of the child as to its habits, hygiene, mode of life and diet. 
A change of climate is often of the greatest benefit. Stomach 
lavage daily, then every other day until vomiting is relieved, 
should be practiced. These patients should live out of doors 
at all seasons, well protected by flannel band and underwear, 
and outside wraps in winter. The feet should be frequently 
inspected and hot-water bottle used if needed. Woolen stock- 
ings should be worn. Daily tub baths, followed by a cocoanut- 
oil rub, should be given. The hygienic care should include the 
frequent change of napkins as soon as soiled or wet, and their 
proper cleansing. 

The diet is most important. If breast fed an analysis, as 
complete as possible, must be made of the mother's milk. If 
over rich in fat, an attempt made to regulate this ingredient. 
If, in spite of every effort to change the character of the milk, 
the vomiting continues a wet nurse, whose baby's age approxi- 
mates the patient's may be procured. If this is unsuccessful, 



254 THE DISEASES OP CHILDREN". 

resort should be had at once to a modified milk, at first prac- 
tically eliminating the fat content. This can best be done by 
utilizing a centrifugal milk in which the fat has been reduced 
below 1 per cent, or a fat-free buttermilk made with the lactone 
tablet can be used. If this is retained the prescription can be 
increased slowly by addition of .25 per cent of fat daily, or 
every other day, until 2 per cent has been reached, unless vom- 
iting recurs when the fat-free mixture is again used. 

Fat-free whey diluted with equal parts of barley water is 
frequently well borne. The first essential in regard to the milk 
is that it should be either certified or inspected. 

If milk is not tolerated in any form, after lavage, give dex- 
trinized barley water in small quantity, by gavage at first, then 
in 2 or 3 teaspoonful quantities, gradually increasing the 
amount. 

The animal broths are frequently well borne, or beef juice, 
expressed immediately before feeding and diluted with quite 
warm water to prevent its coagulating. 

It may be necessary to continue the use of gavage for several 
days. 

One great mistake is made in these cases in trying so many 
foods in a short space of time. Kind neighbors and friends 
harass the mother frantic by suggestions as to this or that food, 
and the physician is asked in regard to each new one in turn. 

It is a mistake to believe these athreptic infants need alcohol. 
It is the worst remedy which can be used, and is responsible for 
much trouble. In giving the proprietary preparations panopep- 
tone and peptonoids, their alcoholic ingredient must be remem- 
bered. 

If the vomitus is very sour good results are sometimes ob- 
tained from the use of bicarbonate of soda in the wash water 
in the proportion of a teaspoonful to the pint of water. 

But little medication is needed or can be given in these cases. 
Save the stomach for food which is most needed. Fowler's 
solution of arsenic is of service, in drop doses in water three 
times a day, and strychnia sulphate, gr. 1/200, to a child of one 
year, assists in toning up the stomach muscle. 

If constipation is present it can best be controlled by use of 



DISEASES OF THE DIGESTIVE SYSTEM. 255 

enemata and glycerine suppositories, alternated, each morning 
at the same time, the child being placed on its chair immediately 
after its use. 

GASTRIC DILATATION (GASTRECTASIA). 

This condition should be differentiated from an enlarged ab- 
domen, so-called pot helly, which is so frequent in yearlings or 
during the second year, this most often being due to a dilata- 
tion of the colon. 

Etiology. — The most frequent cause in new-born babies is 
pyloric obstruction or stenosis. " The next is a stretching of the 
muscular wall due to fermentation and decomposition of the 
food contents, as occurs in chronic gastritis. It is a manifesta- 
tion of general nutritional disorders as in rachitis and tuber- 
culosis. Frequent attacks of acute indigestion; too frequent 
eating and improper foods are also causes. 

Pathology. — The changes in the stomach vary in these cases, 
as found postmortem; often great evidences of chronic gastritis 
are present. The degree of dilatation also varies, as postmortem 
change may show considerable contraction in a stomach which 
had been shown to be enlarged before death. 

Symptoms. — These are as outlined in the previous section in 
chronic vomiting; sluggish circulation; waxy color; cold ex- 
tremities ; thirst ; poor appetite ; coated tongue ; high-colored 
urine; constipation. Percussion shows an increased area of 
stomach resonance, perhaps below the umbilicus, and this is con- 
firmed by introduction of water slowly through the stomach tube 
to point of tolerance. Air injected into the stomach should never 
be employed as a diagnostic procedure in a child because of the 
danger of rupture of the stomach. 

Prognosis depends upon the cause, and if not organic upon 
the early diagnosis and early removal of the cause. 

Treatment is practically that of chronic gastric catarrh. Re- 
lieve the stomach of its fermenting contents, with sufficient wash 
water to have it return entirely clear. Wash daily at first then 
twice and finally once a week, continuing several weeks at least. 
Small quantity of food, predigested at first, at two or three 
hourly intervals, liquids entirely at first. 



256 THE DISEASES OP CHILDREN. 

Nux vomica, 1 or 2 drops of the tincture to a child of t\^o 
years three times a day, well diluted, is beneficial. Careful 
attention to the bowels, the wearing; of an abdominal binder; 
daily baths, general rubbing, and moderate exercise in the fresh 
air will be found very beneficial. 



CYCLIC VOMITING. 

Known also as recurrent or periodic vomiting. It is a condi- 
tion characterized by severe vomiting and prostration with but 
little fever as a rule, in which no active cause, as indiscretions of 
diet, can be traced. 

Etiology. — This is obscure and has been the subject of much 
conjecture. It is doubtless due to an increased acidity of the 
fluids of the body from some disturbance of elimination and 
absorption. There is an acetone odor to the breath, and symp- 
toms of a toxemia are present. Acetone bodies, diacetic acid 
and oxybutyric acid are found in the urine. There seems to be 
a fairly uniform decrease in uric acid elimination. The basis 
of the trouble seems to be a disturbance of metabolism rather 
than an error of digestion. My own cases have failed to reveal 
any uniform digestive disturbance preceding the attacks, or any 
special article of diet as responsible for them. The starchy 
foods have been thought by some to be a cause. 

Symptoms. — Cyclic vomiting rarely occurs in infancy, but 
is more frequently seen in children between 5 and 10 years of 
age. My cases have been about evenly divided in the sexes, 
though girls are said by some observers to be most often affected. 

The onset is usually sudden, and without any dietary indiscre- 
tions. The vomiting may begin in the night, or the child wakens 
in the morning, heavy and dull, and complains of nausea, per- 
haps of pain in the abdomen, which is soon followed by vom- 
iting. If vomiting occurs at night the supper may be vomited 
undigested, if later in the morning, the first vomitus may be only 
fluid. The child continues to vomit at frequent intervals, with 
retching between, the vomitus being principally mucus, perhaps 
bile-stained and a few streaks of blood. Any attempt to admin- 
ister medicine, food or water results in its rejection at once. 



DISEASES OF THE DIGESTIVE SYSTEM, 257 

As a result of the continuous vomiting and retching, pros- 
tration develops early, the pulse is accelerated, the child drops 
back after each attack prostrated, the face is pallid, the eyes 
sunken, lips and tongue parched, the latter coated; abdomen 
retracted, urine highly colored and scant, and the characteristic 
sweetish or acetone odor to both the urine and the breath. 

As a rule there is no temperature, though in one of my cases 
the temperature rose to 102° F. in a number of attacks. Con- 
stipation is the rule, though usually a movement can be obtained 
by an enema. 

The duration of the attack is always 30 to 48 hours, and it 
may last for three or four days. The frecjuency of the vomit- 
ing is gradually lessened as the disease progresses, and I have 
seen a child in an hour's time after severe vomiting call for 
water and retain it and everj^thing given subsequently. There 
is no regularity as regards the time of the recurrence of the 
attacks. One of my cases, under observation for two years or 
more, had a recurrence on an average of once every four months, 
though not regularly at that interval. In this case the attacks 
were undoubtedly rendered less severe and more infrequent 
by the alkaline treatment. 

Diagnosis. — The diagnosis must be made between meningitis, 
appendicitis and organic lesions of the kidney. The failure of 
brain symptoms to appear eliminates meningitis from considera- 
tion, though it should always be thought of. Urinary analysis 
is of importance in ruling out kidney lesions, and this is a 
diagnostic aid which is too frequently overlooked. 

The presence of acetone in the urine is confirmatory evidence 
of cyclic vomiting. Among the tests for acetone are the 
following : ^ 

1. Liehen's Iodoform Test, as modified by Ralfe, is as fol- 
lows : 20 grains of potassium iodide are dissolved in a drachm 
of liquor potassaB and boiled; the urine is then floated upon the 
surface of the fluid in a test tube. At the point of contact a 
precipitation of phosphates occurs, which, if. acetone be present, 
becomes yellow and studded with yellow points of iodoform. 

A more delicate method of application of this test is to first 
distill a small quantity of the urine and apply the test to the 

iPurdy: "Practical Uranalysis." 



258 THE DISEASES OF CHILDREN. 

distillate. This test has one disadvantage; lactic acid and ethyl 
alcohol behave with it similarly to acetone. 

2. Chaiitard^s Test. A drop of aqueous solution of magenta 
decolorized by sulphurous acid gives, with fluids containing 
over 0.01 per cent of acetone, a violet color. This appears in 
dilute solutions after four or five minutes. 

3. Le NohWs Test. On adding an alkaline solution of so- 
dium nitroprusside — so dilute as to have only a slight red tint — 
to a fluid containing acetone a ruby-red color is produced, which 
in a few minutes changes to yellow, and on boiling, after adding 
acid to a greenish-blue or violet. A quarter of a milligramme of 
acetone can be thus detected. 

4. Baeyer's Indigo Test. A few crystals of nitrobenzalde- 
hyde are dissolved by heat in the suspected urine; on cooling 
the aldehyde separates in the form of a white cloud. The mix- 
ture is then made alkaline with dilute sodium solution, and, if 
acetone be present, first yellow, then green, and lastly an indigo- 
blue color will appear within 10 minutes. 

5. Reynold's Test. This test depends upon the fact that 
acetone promotes the solution of mercuric oxide. The test may 
be conducted as follows : The yellow precipitate of mercuric 
oxide, obtained by the reaction of mercuric chloride with an 
alcoholic solution of potassium hydrate is added to a small 
quantity of the urine, which is shaken and filtered. To the clear 
filtrate ammonium sulphate is carefully added, and if acetone 
be present some of the mercuric oxide is dissolved and a black 
ring of sulphide of mercury appears at the plane of contact be- 
tween the two liquids. 

Prognosis. — A few cases have been reported with fatal ter- 
mination, but these are very unusual. They recover in from 
two to four days. 

Treatment. — Active treatment during the attack is of no ser- 
vice. Nothing should be given by the mouth except perhaps 
a preliminary draught of water for the purpose of Avashing the 
stomach as it is immediately vomited. The best results are ob- 
tained from high rectal injections, first for the purpose of evacua- 
tion and followed by an injection of a solution of bicarbonate of 
soda, 2 drachms to the pint, with the purpose of having it re- 



DISEASES OF THE DIGESTIVE SYSTEM. 259 

tained. These enemata should be alternated at four-hour inter- 
vals with predigested milk in quantities not to exceed 4 ounces 
given through a catheter into the sigmoid if possible. 

If the retching is very severe and the prostration extreme, 
the use of codeine, sulphate, grain %, to a child of five years, or 
morphia sulphate, grain y^o, "^^'ill gi^'© good results. 

As soon as the vomiting ceases and the child asks for water 
it can be given tentatively. Crushed ice at first, small quantity 
of water, and repeated in larger amounts at short intervals, 
then a broth followed by diluted skimmed milk. As soon as 
possible a cathartic should be given, cascara or a part of a bottle 
of citrate of magnesia. 

In the interval between the attacks, the regular administra- 
tion of bicarbonate of soda in 3 grain doses, four times a day, 
over a period of three or four weeks, with a week's rest, and a 
resumption of it at the end of that time for another three weeks, 
and so on for four months, will lengthen the interval between 
attacks. IMilk of magnesia can also be used with benefit. 

The diet should be a mixed one, a very moderate amount of 
meat, and sparingly of cereals, no raw fruits, otherwise the diet 
is not restricted. 

If an attack seems imminent the dose of soda should be in- 
creased to double, 6 grains every three hours. 

Some children cannot be persuaded to take the soda by the 
mouth. This was the case with one of my patients who readily 
submitted to its administration twice daily in an enema. 

If there is a history of rheumatism the salicylates should be 
given but not as a routine. 

COLIC. 

Special consideration of this symptom is made necessary be- 
cause of the frequency with which it is encountered in infancy. 
It must be borne in mind, however, that the average mother 
or nurse attributes every crying spell an infant has to the colic, 
and a popular belief among the laity is that every child is likely 
to have colic until it is three months old. 

When a history is given of crying, with a tense abdomen and 
audible rumbling of gas in the intestine und the frequent eructa- 



260 THE DISEASES OF CHILDREN. 

tion of gas from the stomach, the condition is probably one of 
colic, but the frequency with which serious intraabdominal con- 
ditions may develop with colicky pains in the abdomen as the 
chief symptom, makes it necessary for careful consideration to be 
given each case in which abdominal pain is a feature. 

The colic which occurs in both breast and artificially fed in- 
fants is due to a fermentation in the stomach and intestines of 
the food ingested and the rapid accumulation of gas, the pain 
being caused by its passing rapidly from the stomach or through 
a knuckle of gut. It may also be due to a spasmodic condition 
of the intestine, produced by an undigested mass of food acting 
as an irritant as it passes through the bowel. In the artificially 
fed a too large carbohydrate content or the use of undextrinized 
cereal diluent may be the cause of the rapid fermentation. 

A breast-fed child may nurse too quickly from a very full 
breast and swallow some air with the milk. It may stop in the 
midst of a nursing, throw off the gas, and resume the nursing. 
If held for a moment on the shoulder, with its abdomen being 
pressed upon, this eructation is facilitated. 

If the rubber nipple through which an artificial feeding is 
taken allows the milk to flow too freely, this same condition 
may obtain, or if the milk is taken too cold the tendency to gas 
formation is increased. Too frequent feeding is also a cause, the 
effect being an indigestion with fermentation. 

Symptoms. — The chief symptom of colic is pain in the ab- 
domen, which causes the child to cry out, the abdomen is tense, 
and with the hand on the abdomen the gas can be felt as it moves 
in the intestines. The weight of the hand may sometimes give 
relief. The symptoms develop shortly after a feeding or, as 
already stated, may come while nursing, either from the breast 
or bottle, due to swallowing air with the milk. 

The child is restless and fretful, its feet and hands are cold, 
and it cannot be pacified in any position. It may fall asleep 
in the midst of its crying and waken with a start to resume. 

It is not uncommon, especially in the artificially fed, when 
the carbohydrate content of the milk is responsible for the gas 
formation, for the symptoms to develop several hours after a 
feeding, and the child may remain awake most of the night. 



DISEASES OF THE DIGESTIVE SYSTEM. 261 

Eelief comes almost immediately after the gas is passed and 
the child falls into a restful sleep. 

Diagnosis. — This must be made from appendicitis, intussus- 
ception and acute middle-ear inflammation. 

In appendicitis there is an area of tenderness and localized 
rigidity. In colic the weight of the hand often affords relief, 
and the whole abdomen is rigid. 

In intussusception a tumor is apt to develop early, Avhich is 
associated with acute constipation and bloody discharges. 
Bloody, mucous movements may be present in the colic which 
is present in acute gastroenteritis, but in the ordinary form of 
colic here described these stools are not seen. 

In the acute middle-ear inflammations the child puts its hand 
to the affected side or picks at the ear, and the character of the 
cry is different, it being more shrill and piercing than the cry 
from colicky pains. 

Treatment. — Prevention. Care must be exercised as to the 
feeding of the child, regularity, quantity, frequency, and in the 
artificially fed the food prescriptions should be carefully con- 
sidered. If the child is newly put upon artificial food the first 
food prescription must be weaker than is necessarj^ for the child 's 
needs, and gradually increased until it gains in weight, in order 
that its digestion be not upset in the beginning. 

.If on the breast, the breast milk should be clinically examined 
by the Holt milk set, and any ingredient found at fault corrected, 
as indicated in a previous chapter. 

During the attach, those remedies are indicated which will 
assist in the dislodgement of the gas. If the gas seems high 
up the administration of peppermint water, half teaspoonful in 
water, will assist the child in belching. 

The elixir of catnip and fennel in 10 or 15 drop doses is a 
serviceable remedy. Hot applications to the abdomen,. the weight 
of the hand on the abdomen, letting the child lie upon a hot- 
water bag on a pillow, face down, holding it over the shoulder, 
causing pressure on the abdomen, are means which are of service 
in obtaining comfort. 

A warm enema, given through a catheter introduced more 
than half its length,, containing a few drops of turpentine, will 



262 THE DISEASES OF CHILDREN. 

dislodge gas low down in the intestine and often produce com- 
plete relief. 

Soothing syrups should never be given as they all contain 
opium. Opium should not be given under any conditions as 
a routine, in fact, only as a last resort. If it is decided that 
opium is imperatively needed, paregoric is the best form, in 10 
or 15 drop doses, well diluted. The bromides are safe, and can 
be used if the child is very restless and cannot be quieted or get 
to sleep. 

GASTRALGIA. 

A sudden and severe pain in the abdomen, principally in the 
epigastrium, which cannot be traced to an indiscretion in the 
diet or any definite lesion of the viscera. 

It is considered to be a neurosis, a neuralgia affecting the 
nerves of the stomach. 

We know nothing which is definite of the etiology or path- 
ology of this condition. It is more than likely associated with 
the rheumatic diathesis, whatever that may be. 

Diagnosis and Symptoms. — The symptoms of gastralgia are 
best considered under the head of differential diagnosis. 

Children, as a rule, do not locate pain accurately, hence when 
a pain is referred to the epigastrium other conditions may be 
present which may have pain as a principal symptom, but re- 
ferred to near or remote organs. Among these may be men- 
tioned a diaphragmatic pleurisy, pneumonia with small pleural 
involvement, vertebral caries of the middorsal region, intercostal 
neuralgia, inflammation of the pericardium, endocardium, or the 
appendix. 

An investigation of the regions giving rise to these conditions 
will usually rule out the more serious conditions. The pain 
in a gastralgia is usually more or less spasmodic, entire relief, 
except perhaps a slight feeling of soreness being experienced in 
the interim between attacks. Rarely there may be nausea, and 
more rarely vomiting caused by the pain entirely, and with no 
signs or symptoms of indigestion. 

Appendicitis should be carefully excluded in making a diag- 
nosis of this condition. 

Treatment. — Rest in bed; heat, either moist or dry, over the 



DISEASES OF THE DIGESTIVE SYSTEM. 263 

abdomen and epigastrium ; counter irritation by a sinapism of 
mustard or turpentine stupe and hot water internally, in which 
has been put a few drops of camphor. During the interim put 
the child on tonic treatment. Fowler's solution in gradually 
increasing doses of a drop at a time, until the point of toleration 
is produced, and change of food, scene and air. 

ACUTE GASTROENTERIC INFECTION. 

Synonyms. — Acute gastroenteritis, summer diarrhea, summer 
complaint. 

Etiology. — There is always a causal relation between the food 
ingested and the development of this condition, infected milk be- 
ing most frequently the cause in the artificially fed. Statistics 
universally show the highest mortality rate among bottle-fed 
children during the first year. It occurs in the breast fed from 
improper and irregular feeding, and frequently in those partly 
nursed and partly artificially fed. It is most often seen in the 
hot summer months though it may occur in winter. 

Institution and tenement house babies are frequently affected. 

Milk in the various steps of its handling from the cow to the 
consumer is more frequently contaminated than any other article 
of food, and being an excellent culture medium both pathogenic 
and non-pathogenic organisms develop with great rapidity if con- 
ditions are favorable. The toxins developed by the bacteria in 
the milk before and after ingestion are responsible for the ma- 
jority of the symptoms present as well as for the invasion of the 
bacteria in the intestinal wall. 

Many organisms have been identified in examination of stools 
from children affected with gastroenteric catarrh or infection. 
The colon group is most often identified, and Escherich has shown 
that this group can develop great virulency. Streptococci are 
also found, especially the streptococcus enteritis which Booker 
claims is of great importance as a causative factor. 

Many other bacteria are found among which may be named 
the bacillus subtilis, bacillus pyocyaneus, proteus vulgaris. 

Pathology. — One who does much postmortem work in these 
cases will be impressed at once with the small amount of macro- 
scopic changes occurring in the stomach and intestine with the 
history of such severe symptoms during the last illness. 



264 THE DISEASES OP CHILDREN. 

Microscopically there is found a loss of epithelium in both 
stomach and intestine, and a general infiltration of the epithe- 
lium. Deep ulceration may rarely be found. The mucous mem- 
brane exhibits, as a rule, a washed-out appearance with here 
and there a reddened area, some mucus adhering to surface of 
the membrane, and the intestine practically empty of contents. 

The small gut will often be found contracted almost through 
its whole extent. Cloudy swelling of the kidney may be found. 

Symptoms. — Several forms are described. It may be mild, 
severe or toxic. Usually without warning the child will vomit, 
often large quantities, apparently much more than had been taken 
at the last feeding. In older children there is apt to be nausea for 
some time after the initial vomiting. There is considerable 
prostration, the child looks sick, is pale and restless. The tem- 
perature rises quickly and may be 102° or 103° F. The stools 
may at first be normal but are followed by undigested, offensive 
ones full of mucus. 

Prognosis. — In previously normal and healthy children the 
prognosis is usually good, but in the athreptic baby recovery is 
not so prompt, and serious sequela are apt to develop. 

In the very young improvement is usually quite prompt or 
the child may quickly succumb, or the condition develop into a 
chronic one. 

Treatment. — Prophylaxis is of the greatest importance. A 
breast-fed child should not be weaned in the midst of the hottest 
months. Only clean, cold milk should be used. If Certified milk 
is not obtainable the best that can be had should be pasteurized 
and kept cold until fed. Scrupulous cleanliness of bottles, nip- 
ples, etc., should be insisted upon. 

As in other gastroenteric disorders the treatment is best con- 
sidered under (1) Dietetic; (2) Medicinal; (3) Hygienic. 

1. Dietetic. First all food should be immediately withheld, 
especially milk, for at least 24 hours. While the nausea lasts, 
no food by the mouth can be retained or assimilated. Milk in 
any form should not be given, as no other food offers so favorable 
a culture medium for bacterial development when taken into 
the stomach. Dextrinized barley water is better taken care of 
than anything else, and can be given in small quantities at 



DISEASES OF THE DIGESTIVE SYSTEM. 265 

the end of 24 hours, or later, if the nausea and vomiting have 
not stopped by that time. To the barley water can be added 
a little beef peptonoids or panopepton which makes it more 
palatable to some, and nutritious also. 

On the third day one of the animal broths, plain or with 
barley water, can be given, and upon the return of normal 
stools, practically free from mucus, milk can be resumed, at 
first in the form of whey, made from fat-free milk, and to this 
may later be added small amounts of skimmed milk, until the 
usual formula can be resumed. The first milk given may be 
in the form of buttermilk, made from fresh milk by the addi- 
tion of the pure culture lactic acid bacteria, and it is frequently 
well taken by children. 

2. Medicinal. If much nausea is present, calomel, dry on 
the tongue, is the remedy of all others. To a child of one year 
give 1 grain of finely-triturated calomel. If not much nausea 
is present and the stools show intestinal irritation early a dose 
of castor oil should be given in order to quickly sweep out the 
decomposing and putrid intestinal contents. 

If much gastric irritation is present and neither remedy can 
be retained, lavage of the stomach gives brilliant results. 

If the initial purgative is given early and dietetic treat- 
ment outlined, strictly followed, further medicinal treatment is 
usually not needed, but if the intestinal irritation continues 
several doses of bismuth subnitrate may be indicated. The fol- 
lowing can be used to advantage : 

I^ Bismuth subnitrat Jss 

(Merck or Squibb) 
Syr. rhei aromatici 3iii 

Aquae destillatae q.s. ad Jiii 
M. (Shake well.) 
Sig. One teaspoonful every two hours, until at least six doses have 
been given. 

To this prescription can be added 5 grains of tannalbin to 
each teaspoonful if the mucus persists and the evacuations are 
very frequent. 

Colon irrigation once daily with the normal salt solution is of 



266 THE DISEASES OF CHILDREN. 

great benefit, especially early when the nausea and vomiting are 
features and there is so much loss of fluids. 

3. Hygienic Treatment. The most important hygienic treat- 
ment consists in the proper care of the food of the child from 
its production until it is consumed ; the proper care of the bottles 
and nipples and the correct modification of the milk for the indi- 
vidual child. Most of these attacks are preventable, and if the 
parent is correctly informed of the dangers attending carelessness 
of detail in the preparation and handling of the child's food, a 
great deal of mortality and morbidity will be prevented. 

The child should be warmly clothed, wearing an abdominal 
binder at all times. It should live out of doors, well protected 
in inclement weather in winter. Daily baths are most impor- 
tant, and during an attack hydrotherapy for pyrexia is specially 
indicated. Great care should be taken of the napkins, which 
should be boiled before using a second time. Regular feeding, 
according to schedule, is most important and should be insisted 
upon. It is of as much importance to give accurate written 
directions in regard to the preparation, care and administration 
of the food as it is for medicine. Do not take anything for 
granted when it comes to the feeding of an infant, especially 
during convalescence from an active gastroenteric infection. 

CHOLERA INFANTUM. 

Definition. — This term is erroneously applied to many cases 
of acute gastrointestinal disturbances, which do not all answer the 
description of this pathologic condition. It is a disease seen 
in children under three years of age, and is characterized by 
great prostration, very rapid wasting, profuse watery discharges 
from the bowel, vomiting of large quantities of fluid, and either 
rapid improvement as a result of treatment or early death. 

Etiology. — No specific organism has been isolated, but the 
symptoms are those of an essentially toxic disease, viz., rapidly- 
appearing prostration, high fever, profuse diarrhea and vomiting. 
It occurs in the very hot weather. 

Pathology. — It is surprising that a condition giving rise to 
such severe symptoms will result in so little gross pathologic 
changes. No constant changes are found in any organ. The 



DISEASES OF THE DIGESTIVE SYSTEM. 267 

intestines are collapsed and show a pale washed-out appearance 
with a denudation of the superficial epithelium. The thin in- 
testinal contents have a yellow color and musty odor. 

Symptoms. — This is usually not a primary disease occurring, 
as a rule, during the convalescence from an acute gastroenteric 
"disorder. There is usually sudden, violent and profuse vomiting, 
at first the contents of the stomach followed by a fluid vomitus 
and considerable retching. A diarrhea soon follows, fecal in 
character at first, the discharges soon becoming entirely fluid, 
soaking through napkins and protecting cloths as soon as passed. 
They occur very frequently, every half hour or oftener, have 
a musty or foul odor, and are practically colorless. But little 
mucus is passed as a rule. 

There is a rapid wasting, the skin is cool, pale and transparent, 
and soon becomes wrinkled from the wasting; eyes are sunken 
and rolled up ; the child lies at first listless and takes no notice 
of its surroundings. The temperature rises rapidly, reaching 
103° F. to 105° F. or 106° F. in a short while. Rarely cases 
may be seen in which the temperature does not rise much above 
normal, if at all, and it is in these that the prognosis is so much 
graver. The pulse is feeble, rapid and without volume, the 
respirations are hurried and shallow, the tongue is at first coated 
but later is denuded of epithelium and becomes red and dry. The 
abdomen is retracted ; the urine scanty ; the fontanelle depressed ; 
there is great thirst but water is usually vomited at once after 
swallowing. Later there may be a shrill cry which is suggestive 
of meningeal irritation. 

Prognosis. — The prognosis is grave in all cases of cholera 
infantum, no matter how slight they may appear to be in the 
beginning. 

The duration is short, improvement either being very prompt, 
or a fatal termination inevitable in 24 or 48 hours. Excessively 
high or a very low range of temperature are grave signs. Some 
infants die within 12 hours in spite of early and scientific treat- 
ment. 

Diagnosis. — No other condition met with in the gastrointes- 
tinal disorders in children presents so severe a picture of serious 
illness. The association of severe vomiting, profuse diarrhea, 



268 THE DISEASES OF CHILDREN. 

rapid wasting, high temperature and prostration is sufficient for 
a diagnosis. 

Treatment. — The indications for treatment are very positive, 
viz., to withhold all food, clearing out of the stomach by stomach 
washing, and the bowel by purgation and enteroclysis, anti- 
pyretic measures, baths or packs. If the wasting diarrhea keeps 
up, the indication is very positive for the hypodermic admin- 
istration of morphia and atropia. Give morphia in dose of 
1/100 grain to child of one year and repeat for its effect. 
Atropia can be given in 1/600 grain and repeated as indicated. 

Enteroclysis and hypodermoclysis are indicated to renew the 
fluids lost in the profuse watery diarrhea. Hydrotherapy should 
be used for the pyrexia, putting the child in the water at 100° F. 
and cool gradually to 85° or 90° F., being careful to use friction 
of extremities and body while in the water. Cold compresses 
should be applied to the head and renewed at frequent intervals 
during the bath. If the temperature is below normal hot water 
should be added to the bath to 110° F. The baths should be pro- 
longed for at least 5 minutes. The addition of mustard to the 
bath water is beneficial. Antipyretic drugs should not be used 
under any circumstances. If stimulation is needed it should 
be used hypodermatically, as it is not safe to rely upon the stom- 
ach for absorption. No drug will give quicker results than 
camphor dissolved in olive oil, gr. xx to §i, and of this solution 
giving 10 or 15 minims hypodermatically. The effect of cam- 
phor is quick but transitory, and should be repeated or supple- 
mented by brandy or digitalis or strophanthus, 1 or 2 minims 
of the tincture of either preparation with the brandy. 

No food should be given by the mouth until all nausea and 
vomiting have ceased and the diarrhea is checked. Small quan- 
tities of sterile water can then be given, 2 teaspoonfuls at a time 
every 15 or 20 minutes, and usually this is taken ravenously. 
If retained a small quantity of dextrinized barley can be given 
to which has been added a few drops of brandy or a small quan- 
tity of panopepton or peptonoids. If the child soon tires of 
barley water, gruels made from the other cereals can be tried, 
rice, granum, wheat flour, etc. Later the animal broths can be 
tried, then whey, to which later, skimmed milk can be added, 



DISEASES OF THE DIGESTIVE SYSTEM. 269 

after boiling the whey. The milk should best be pasteurized at 
first. A rise in temperature with a return of the diarrhea or 
vomiting after the resumption of a milk feeding, is evidence 
enough that the milk should be discontinued at once, and a pur- 
gative given to wash out the undigested masses and the same 
routine again begun. 

Tf the same experience is encountered on again giving cow's 
milk, condensed milk should be tried, as this is low in fat per- 
centage, and often can be taken care of when modified cow's 
milk cannot. 

The termination of these cases is either in prompt recovery, 
early death or a development of a severe enterocolitis. 

ACUTE ENTEROCOLITIS. 

Synonyms. — Ileocolitis; dysentery; enteric infection; inflam- 
matory diarrhea amd enteritis. 

In this condition there are more or less severe changes occur- 
ring in the intestinal mucous membrane, usually without in- 
volvement of the stomach. 

Etiology. — This trouble is rarely primary, following, as a 
rule, upon some one of the acute forms of gastric or gastrointes- 
tinal disorders. 

The Shiga bacillus is very often found, also the colon bacillus 
and streptococcus. Age plays an important part in the etiology. 
It is most frequent during the second year, or the much-dreaded 
''second summer," not because the teeth are being cut at this 
time but because the child is allowed to eat a too liberal diet 
during this period and acute gastrointestinal troubles follow. 
It may complicate the acute exanthemata or pneumonia. Bottle- 
fed babies are prone to develop this condition. Bad hygienic 
conditions predispose to its development as do the nutritional dis- 
orders, rachitis, scorbutus, and tuberculosis. 

Pathology. — As implied by the name given this trouble, the 
process is limited largely to the colon and the lower portion of 
the ileum, in a small percentage only the colon may be affected. 
The stomach may show signs of catarrhal inflammation but as a 
rule is normal. Three grades are usually described, the mild, 
or acute catarrhal; tdcerative; and pseiodomemhranous. 



270 THE DISEASES OF CHILDREN. 

1. Catarrhal. One is impressed with a condition seen at 
autopsy in fatal cases of catarrhal enterocolitis, viz., the com- 
paratively slight changes seen macroscopically in the intes- 
tines. The stomach and upper part of the small intestine will 
show changes varying from a very slight congestion here and 
there, with small amounts of mucus loose in the bowel, or bath- 
ing the surface of the mucous membrane, to a deeply-congested 
area at frequent intervals. The deeply-congested areas are 
found at or near the cecum. Pyer's patches are swollen, and 
the general surface of the mucous membrane appears granular. 
On section the mucous membrane shows a loss of superficial 
epithelium in some places perhaps approaching the ulcerative 
stage. There is a general round-cell infiltration of the mucous 
membrane causing thickening and some swelling of the lymph 
nodes. 

2. Ulcerative. In this form there may be a follicular ulcer- 
ation, being limited to the solitary follicles or a coalescence of 
a number of these forming a large ulcerated area. The ulcera- 
tion may also involve a large area and be of a catarrhal variety 
entirely, and quite superficial. Ulcers are rarely found above 
the lower 12 or 15 inches of the ileum, and are chiefly located 
in the colon. In those areas where the follicles have coalesced 
the destructive process is deep, penetrating to the muscular 
coat, but in the milder form it is superficial. The mucous mem- 
brane has a pitted appearance. 

3. Pseudomemhranoiis. In this form also the process is 
chiefly located in the lower ileum and most of the colon. There 
is a general thickening of the intestinal wall, due to round-cell 
infiltration, congestion and attachment of the pseudomembrane. 
The whole surface of the colon may be covered with membrane 
or only a portion of it, with deeply-congested areas here and 
there, from which the membrane has become detached. The 
process is rarely found in patches, but it may be limited to the 
extreme lower end of the colon and the rectum. 

The pathological changes found elsewhere depend entirely 
upon the complications existing during the attack. It is not 
an unusual thing to have a patchy bronchopneumonia, especially 
in the prolonged cases, and in those who are reduced in vitality, 



DISEASES OF THE DIGESTIVE SYSTEM. 271 

the athreptic, marasmic child being much more liable to develop 
such complications. Nephritis may very rarely occur as a com- 
plication. 

Symptoms. — Clinically, it is often very difficult to differen- 
tiate the three varieties of this condition described under patho- 
logical changes. I have seen cases with a large number of 
mucous, bloody stools, with other symptoms indicating a severe 
ulcerative type, in which the autopsy findings did not reveal any 
changes usually in the ulcerative type. 

If primary, an enterocolitis usually begins suddenly, with 
vomiting, a rise of temperature varying from 102° to 104° F., 
with proportionate increase in pulse rate, and the child appears 
sick from the onset. 

The vomiting as a rule is not severe or often repeated, and is 
soon followed by abnormal evacuations. The first part of the 
first stool may be normal, the last loose, perhaps containing 
undigested food and mucus. The character of the movements 
rapidly changes, they are frequent, perhaps averaging once an 
hour; thin, contain much mucus, and vary in color from a very 
dark yellow to many shades of green. Some of the stools may 
consist simply of glary mucus. The-y may or may not, in the 
severe cases, contain blood varying from a few streaks in the 
mucus to a larger quantity. The stools will change in color, 
after being passed, and when a napkin is examined the hour it 
was soiled should be known. After standing they frequently 
become very green in color, turning from a light brown to a 
very much lighter shade of green. Frequently there is tenesmus 
with each stool, the rectal mucous membrane may protrude as 
the child strains. The mother will often state that water or 
nourishment of any kind "passes directly through," meaning 
that the ingestion of anything causes peristalsis and a move- 
ment results. If there is much toxemia and high temperature 
the child will probably lie in a stupor; with a lower temperature 
it is apt to be fretful and restless. 

It is not infrequent that they have muscular twitchings or 
general convulsions. 

The high range of temperature is usually of short duration, 
there beino^ an elevation of 2° or 3° F. during the rest of the acute 



272 THE DISEASES OF CHILDREN. 

stage. As a result of the toxemia, frequent loose actions, long 
febrile course and restricted diet ; there is rapid wasting, the eyes 
become sunken, the skin is wrinkled and the fontanelle sunken, 
the picture presented being anything but a promising one. 
Thirst is apt to be a prominent symptom. 

Course and Duration. — The duration in the severe form of 
enterocolitis is usually comparatively short, the child growing 
rapidly worse from the onset, terminating fatally within a week 
or 10 days, or the acute symptoms subside and the convalescence 
is prolonged for several wrecks, or an improvement follows 
promptly from the acute symptoms and the child succumbs to a 
complicating bronchopneumonia. 

Cases may terminate fatally in three or four days, in spite of 
diet and treatment. 

Milder cases are more often seen, but the general symptoma- 
tology is the same, a less abrupt onset, not so frequent vomiting, 
fewer stools, but they have the same general characteristics, nerv- 
ous symptoms less marked, convulsions unusual, and the 
general duration is shorter. The acute symptoms usually end 
in about a week, and the convalescence while slow is steady. 
Indiscretions in diet result in very frequent relapses and a 
chronic enterocolitis is the natural sequence. This is especially 
true when milk feedings are resumed too quickly and in prescrip- 
tions too rich in both fat and proteids. 

Prognosis. — Several factors materially influence the prognosis. 
The younger the child the more grave the prognosis; severe 
attacks under six months are usually fatal. 

Artificially-fed infants bear an attack poorly ; in the athreptic 
and poorly -nourished the results are poor ; cases in which a di- 
gestive disturbance has been neglected always do badly, hence 
the prognosis is decidedly better when treatment is begun 
promptly. 

Treatment. — As just stated, on the promptness with which 
treatment is instituted in these cases depends in a great measure 
the results. The treatment can be considered under four heads ; 
1, preventive treatment; 2, general and dietetic treatment; 3, 
medicinal, and 4, hygienic treatment. 

1. Preventive. Neglect of apparently trivial attacks of 



DISEASES OF THE DIGESTIVE SYSTEM. 273 

gastroenteric disturbances, continuance of the usual diet in the 
presence of what is generally considered a trivial attack of vom- 
iting and diarrhea, is responsible for more of these cases than 
any other cause, and undoubtedly increases the mortality 
greatly. 

Mothers should be educated in the first place in the importance 
of a pure milk supply in the artificially fed, the value of absolute 
cleanliness in the care and preparation of the child's diet; the 
necessity for the immediate withdrawal of all food upon the 
first appearance of vomiting or an abnormal stool and early 
medical treatment. If these requirements were met in all cases, 
the frequency of the severe cases and the mortality would be 
greatly reduced. 

2. General and Dietetic. If the vomiting is recurrent the 
stomach should be washed, using warm, filtered and boiled 
water. If on a general diet or modified or whole milk, all food 
must he withdrawn at once, and not resumed until both the stom- 
ach and intestines have had a rest, and then resumed very grad- 
ually. The first food given should be a dextrinized plain barley 
water or combined with any of the animal broths, in equal parts, 
or a small quantity of panopepton or liquid peptonoids. The 
latter are of value chiefly because of their alcohol content, having 
relatively small food values. i\Iilk can be resumed after the 
subsidence of the symptoms by the use of whey, made from fat- 
free milk, combined with barley water or a diluted fat-free but- 
termilk made with a pure culture of lactic acid bacteria. 
Beef juice has a tendency to increase the diarrhea, often causing 
watery movements. The food must be changed from time to 
time also, as the child is apt to become tired of one or two of the 
combinations mentioned. If it refuses food entirely, it must 
be given by gavage. Do not resume milk feeding too suddenh^ ; 
add 1 or 2 drachms of skim milk to a barley-water feeding, 
once during the day : if this is taken care of give the same quan- 
tity twice the next day, the next give 2 teaspoonfuls, and so on, 
gradually increasing the milk. 

A valuable agent, but a much-abused one in these cases, is 
colon irrigation. It need not be used oftener than twice in the 
24 hours, once being usually sufficient; a soft Nelaton catheter, 



274 THE DISEASES OF CHILDREN. 

well anointed, should be used, and if there is much straining 
and a tendency for the bowel to expel the tube, the irrigating 
bag should be held but a small distance above the buttocks. If 
there is much mucus of the white, glary kind, the irrigation can 
be of an astringent solution to advantage, a heaping tablespoon- 
ful of tannic acid, dissolved in a quart of water. For an ordi- 
nary irrigation use the normal salt solution, using not less than 
2 quarts at one irrigation. The temperature can be as low as 
85° F. in febrile cases, or 95° to 98° F. where the temperature 
is not so high. Tub baths are given for cleansing purposes as a 
routine, but should be repeated as an antipyretic measure. Me- 
dicinal antipyretics should never be used. 

3. Medicinal. Shotgun diarrheal prescriptions should never 
be given. Only such drugs should be used as there is a special 
indication for. As soon as the first symptoms appear a purga- 
tive must be given, castor oil, if the stomach is in condition to 
retain it, otherwise calomel, in 1 grain doses to a child of one 
year or over. One of the most useful is bismuth and a pure 
subnitrate preparation is advised. The usual dose given by 
the average practitioner is much too small. It should be given 
in not less than 10 grain doses until at least 60 to 80 grains have 
been taken in 24 hours. It is a valuable agent, acting mechan- 
ically on the congested and inflamed mucous membrane. An 
astringent can be added if the movements are very frequent and 
contain much mucus. Tannalbin or tanningen in 3 to 5 grain 
doses can be added to the bismuth for their astringent effect. If 
there is much odor to the evacuations salol will be found of serv- 
ice, given in 2 to 4 grain doses every four hours. 

Stimulation may be needed, but should be reserved for active 
indications. Hypodermatic injection of strychnia sulphate gr. 
1/200 or atropia sulphate gr. 1/400 may be given. 

Opium is of service in those cases with very frequent move- 
ments and a great deal of tenesmus. Dover's powder, in 14 to 1 
grain doses, is a valuable remedy. Opium in any form should 
not be combined with a prescription, but ordered separately and 
given at the same time if need be. This is important, as the 
opium is usually the first remedy to be discontinued. Kerley 
has recommended the addition of 1 grain of sulphur to the bis- 



DISEASES OF THE DIGESTIVE SYSTEM. 275 

muth preparation, if the movements do not turn black after its 
administration for a few days. For the tenesmus, 3 or 4 drops 
of the deodorized tincture of opium can be given in 2 or 3 
drachms of starch water as an enema, following an irrigation, if 
the Dover's powder is ineffective. 

The after-care of these patients is most important. Medica- 
tion in convalescence is not specially indicated, as they usually 
respond quickly to proper diet as soon as it is safe to resume it. 

4. Hygienic. In no class of cases does a complete climatic 
change have so beneficial an action as in children convalescing 
from enterocolitis. From points south of Mason and Dixon's 
Line no other change is more beneficial than removal to points 
in Michigan. The large amount of water through this State 
imparts a life-giving something to the air which works wonders 
in these cases. They unquestionably get back upon a gaining 
diet much quicker in this climate than at home. Some cases do 
well when simply moved from the city to the country nearby — 
others do better in the mountains or at the seashore. 

Great care should be exercised in keeping the soiled napkins 
clean. They should be boiled daily. In institutions the nap- 
kins from the well should be treated separately from the in- 
fected ones. These cases should be isolated in hospitals and 
institutions, and not too many kept in a ward or room. Their 
feeding utensils should be kept apart from the general supply 
and frequently boiled. 

If in institutions but few should be put in the same ward, 
allowing plenty of air space to each infant. 

CHRONIC ENTEROCOLITIS. 

Synonym. — Chronic Gastrointestinal Indigestion. 

Acute enterocolitis frequently ends in the chronic form. The 
acute symptoms subside, or perhaps the child shows a decided 
improvement, it is fed indiscreetly, and a second attack follows, 
which lapses into the chronic form. It is found in hospital 
cases of acute form which have improved and been allowed to 
return to unhygienic homes and bad food, with the chronic con- 
dition following. 

It may be seen at any age of childhood, an inflammation of 



276 THE DISEASES OP CHILDREN. 

the colon alone being more frequent, however, in older children. 

Pathology. — There is usually a catarrhal inflammation of 
the mucous membrane of the colon, and the last 10 or 12 inches 
of the ileum. The inflammatory condition extends into the 
tubular glands and many of these are destroyed by pressure. 
There may rarely be an ulceration of the mucous membrane. 
The mesenteric glands are enlarged. 

The most frequent complication in this form of trouble is a 
pneumonia, hence we find the lungs involved to various degrees, 
from a hypostatic condition to consolidations here and there 
through the lung, of the bronchopneumonia type. 

Symptoms. — The chief general symptom is a more or less 
rapid and progressive loss of weight, with abnormal evacuations 
numbering 6 to 10 in the 24 hours, or there may be twice as 
many. The stools are abnormal in color, content and consis- 
tency. They may be mushy and be composed mostly of a 
greenish mucus, or they may lose all color and be light and 
contain pus. They may or may not contain blood, usually do 
if there is much strailiing. The color varies from a yellow to a 
brown, with all shades of green. If on milk or a general diet, 
curds and undigested food are present. 

The child quickly develops into that condition known as ath- 
repsia or malnutrition, it emaciates quickly, its abdomen is 
distended, it is restless, fretful and cries a good deal, the fon- 
tanelle is depressed, skin wrinkled, and it soon develops the old- 
man facies, with tightly-drawn skin over the face. It lies upon 
its back or side with legs drawn up, the skin of the legs and 
arms is in folds, and there is no subcutaneous fat. The tem- 
perature is below normal, and may reach but 95° F. in the rec- 
tum. Owing to the many discharges the skin of the buttocks 
may show an intertrigo, or at least a severe redness. Food will 
be generally taken with greediness. The pulse is weak, the feet 
and hands cold. Occasionally, shortly before death, the feet 
and hands may be quite swollen. 

Diagnosis. — The chief trouble to be differentiated is from 
tuberculosis, and in the absence of marked intestinal disturb- 
ance this may be difficult. In those cases which have a distinct 
tubercular family history, and in certain hospital cases it may 



DISEASES OF THE DIGESTIVE SYSTEM. 277 

be more puzzling. It probably cannot be positively determined 
without the use of tuberculin which' is one of the diagnostic 
methods advised. When there is distinct involvement of the 
chest the diagnosis of tuberculosis is easier. 

Prognosis. — This is universally bad. While some cases may 
show an improvement even after several weeks of an apparently 
hopeless condition, the majority succumb. The prognosis is in- 
fluenced by the age, surroundings, intelligence of mother or 
nurse, and feeding. The prognosis in children under one year 
of age is very grave. 

Treatment. — 1. Hygienic. Fresh air and a change of cli- 
mate, if possible, is of prime importance. The remarks on page 
275 relating to climatic change in the treatment of acute en- 
terocolitis is true in the chronic form. If thoroughly pro- 
tected from exposure, the child should be out of doors almost 
continuously. Kegular baths should be given, but without ex- 
posure. As described in the previous section the napkins should 
be carefully washed, and the child changed promptly when one 
is soiled. An abdominal binder should be worn in addition to 
the shirt. The binder in the form of the sleeveless shirt, made 
with shoulder pieces and tapes in front and back to pin to the 
napkin, is best. Stockings should always be worn and flannel 
skirt also. 

2. Dietetic. In no other condition are precise instructions in 
regard to feeding so necessary. Written directions as to choice, 
mode of preparation, time, temperature and quantity of the food 
should be given the mother. The diet should be concentrated, 
leaving little residue. The digestive capacity for carbohydrates, 
fat and proteid is much enfeebled, and food within reach of the 
digestive capacity should be given. Fat-free whey ; animal 
broths with fat removed ; dextrinized cereals ; predigested milk, 
when it can be borne, are the foods which can be tried. If one 
seems to cause a recurrence of the condition it is discontinued. 
Regularity of feeding is most important, not oftener than every 
two hours, and food given in 2 or 3 ounces at a feeding. Over- 
feeding is greatly to be feared. If tlie child shows an improve- 
ment eggs can be added to the list, peptonized milk, lactone 
buttermilk, scraped beef, etc. A gain in weight, or if it stops 



278 THE DISEASES OF CHILDREN. 

losing with coincident improvement in the stools, is an assurance 
the child is improving. 

3. Medicinal. Castor oil at the onset and repeated occasion- 
ally is a valuable agent, 1 or 2 teaspoonfuls to an infant of one 
year. An emulsion of castor oil containing 10 drops to a dose 
is frequently beneficial. If not retained calomel in 1 grain 
dose should be given. 

The same directions as to the administration of opium in 
the acute form obtain in the chronic. It should not be com- 
bined with any other prescription. Dover's powder, in % to % 
grain doses, or paregoric, 10 or 15 drops, are the best prepara- 
tions. Bismuth is a valuable agent and can be given plain or 
in combination with tannalbin, if an astringent is needed, and 
salol, if there is much fermentation and odor present. Astring- 
ent injections should be given when there is much mucus, other- 
wise a colon irrigation of normal salt solution, under the same 
general rules as mentioned before. 

Stimulants should not be given unless there is a decided indi- 
cation for their use. Cod liver oil, internally, is of great service 
in convalescence when tolerated by the stomach, and frequently 
it can be taken when no other fats can be borne. 

CONSTIPATION. 

Constipation is a symptom, not a disease. It is more or less a 
relative term, but it exists when the bowel movements occur less 
frequently than is ordinary; when it is accomplished with diffi- 
culty, when the fecal matter is reduced in quantity, and is 
drier than normal. This is a common affection in children. 

Etiology. — The chief cause of constipation in infancy is the 
conformation of the colon, especially the sigmoid flexure. Ow- 
ing to the shallow infantile pelvis and the relatively long mesen- 
tery of the sigmoid, this portion of the large bowel is freely 
movable, often found beyond the middle line of the abdomen. 
During the first few months after birth the descending colon 
grows at the expense of the sigmoid and the apparently superflu- 
ous sigmoid is shortened. Because of this freely movable length 
of colon just above the rectum, it acts as a storehouse for fecal 
accumulations and is with difficulty emptied. Its contents move 



DISEASES OF THE DIGESTIVE SYSTEM. 279 

slowly and absorption takes place readily, causing increased 
dryness of the fecal mass. Added to this is the distension which 
comes from fermentation, rendering movement less likely to 
occur. 

Constipation beginning soon after birth, especially when asso- 
ciated with vomiting should cause pyloric stenosis to be sus- 
pected. The fear of pain caused by a fissure may be a volun- 
tary cause of constipation. 

Late in childhood after typhoid fever, or an attack of appen- 
dicitis, constipation is probably due to bands of adhesions acting 
as a mechanical cause of constipation. 

Dietetic causes of constipation should be carefully consid- 
ered. A deficiency in fat, in both breast and modified milk, 
with a relatively large proteid percentage is a cause. Too long 
continuance of a milk diet in late childhood and the absence of 
mixed food, carbohydrates, etc., may also act as a cause. Too 
little water in both the artificially and the breast fed ; prolonged 
use of a Pasteurized or sterilized milk may act as causes. 

Loss of muscular tone, such as follows the acute exanthemata, 
typhoid fever, or as is found in rickets and athrepsia, is a fre- 
quent cause. Failure to begin with regular habits and encour- 
agement to have daily evacuations at a regular time will cause 
constipation. It often follows an attack of acute enterocolitis, 
due sometimes to the too prolonged use of astringent drugs in 
the treatment of the acute condition. The use of soothing syr- 
ups, all of which contain opium, for the cure or alleviation of 
colic is a potent factor in the development of chronic con- 
stipation. 

Symptoms. — A normal number of evacuations is a purely rel- 
ative term, for what is normal to one baby is not to another. 
One child may be entirely normal with one evacuation and an- 
other may have two natural daily movements and be uncom- 
fortable without that number. 

The infant will normally have from two to four soft move- 
ments; later from the fourth to the sixth month they become 
less frequent, perhaps only two a day, and during the latter 
half of the first year the constipation usually begins. It will 
have one natural action a day, or it must be assisted to have 



280 THE DISEASES OF CHIIjDREN. 

that. If it has the one action a day and this is firm and hard, 
it is constipated. 

"When a child has not had a movement for one or two days 
it may or may not present symptoms. It is, however, apt to be 
fretful and cross, there may be colic, nearly always flatulency, 
with distension of the bowels. 

Occasionally a case may be seen which has passed several 
large, firm, hard movements which have so stretched the sphinc- 
ter muscle as to cause the mucous membrane to tear. This does 
not heal, and a fissure of the anus results. Because of the pain 
caused by a movement when a fissure is present the child volun- 
tarily suppresses an action of the bowels and will not sit upon 
the chair or vessel. The pressure of the accumulated fecal 
masses in the rectum causes a passive congestion of the hemor- 
rhoidal plexus of veins and hemorrhoids result. A prolapsus 
of the mucous membrane may also occur as a result of the strain- 
ing. In some cases as a result of acute constipation, especially 
when previously regular actions have obtained, there may be 
vomiting with a slight rise of temperature of 2° or 3° F. They 
are restless, cross and peevish, have little appetite and sleep 
poorly. 

Prognosis. — This is variable, depending upon the cause, age 
of child, duration, presence of complications, etc. Usually, how- 
ever, it is fairly good and by faithfulness in carrying out direc- 
tions will good results be had. 

Treatment. — The chief indication is regularity in obtaining 
evacuations from the bowels. As early as six months the child 
must be taught to use the chair or vessel. It should not be 
allowed to sit too long upon these, because of the tendency to 
development of hemorrhoids. If there is no inclination in 15 
minutes to strain and assist the movement, a glycerine, pencil 
suppository or small amount, 8 or 10 ounces, of water thrown 
into the rectum from a fountain syringe, held about 3 feet 
above the child should be used. In using the syringe it is well 
to attach a soft-rubber catheter to the hard-rubber syringe tip 
in order to avoid injury to the rectum in its introduction. This 
will cause the child to strain to expel the suppository or water, 
and an evacuation results. 



DISEASES OF THE DIGESTIVE SYSTEM. 281 

Endeavor to locate the cause of the trouble. If it is dietetic, 



as indicated in the description of the etiology, correct this. If 
the mother's milk shows by an examination an excess of proteids, 
have her eat less meat, take more exercise and drink more water. 
If the child is on modified milk increase the fat content in the 
prescription, or if the age will permit, begin the varied diet 
and increase the amount of water taken. The average child, 
W'hether breast or artificially fed, is given too little water. 

The use of dextrinized gruels is of service as a diluent when 
modified milk is given, especially an oatmeal Avater or one of the 
flours made by the Cereo Company, Tappan, N. Y. 

Abdominal massage is of great benefit, beginning the rub- 
bing in the right iliac fossa, extending from this point over the 
course of the colon. This should be done with the child upon 
its back upon a firm mattress. 

In the athreptic or marasmic infants, especially, and to others 
also, the administration of orange juice is of great assistance in 
this condition. The juice of half an orange can be given twice 
a day, not too close to a milk feeding. 

In children after the second year good results are obtained 
from giving muffins or biscuits made from whole wheat flour, 
plain or mixed with bran. Cooked fruits are of value also, as 
stewed prunes and apples. Spinach and asparagus can be given 
older children to advantage. 

Medicinal. Medicine should not be resorted to until all other 
means of treatment have been exhausted. Of all the remedies 
suggested for constipation cascara sagrada is one of the most 
serviceable. It can be .disguised by aromatics without its effi- 
ciency being destroyed. Almost any of the aromatic prepara- 
tions can be used to advantage. It acts as a tonic to the intes- 
tinal musculature, and from the maximum dose (20 to 60 drops), 
if used in connection with dietetic and other measures, can be 
reduced in a short time to the minimum dose (10 drops'), and 
then discontinued. 

An occasional dose of calomel is of benefit, especially when 
the actions are very light in color. Rhubarb and soda can often 
be used to advantage as f ollow^s : 



282 THE DISEASES OP CHILDREN. 

B Pv. rhei 3iss 

Sodii bicarbonat 5i 

Syr. tolutan ^i 

Aquse destillatae q.s. ad 3iii 
M. ft. Sol. (Shake.) 
Sig. One teaspoonful once or twice a day. 

Syrup of tamarinds is of benefit used as cascara, 1 or 2 tea- 
spoonfuls at a dose, at bedtime, usually but one being required. 

Sodium phosphate, plain or effervescent, taken in the morn- 
ing before breakfast, well diluted, in certain cases is of benefit. 
Two to five grain doses of carbonate of magnesia may be ef- 
fective. 

In cases in which there is an impaction of the rectum and sig- 
moid an injection of first, a stimulating enema containing a 
half ounce of glycerine and of Rochelle salts can be used. If 
this is not successful, an emulsion of 6 ounces of fresh ox gall in 
1 pint of warm water may be effectual, or the injection of 6 
ounces of molasses and enough milk to make a pint may be 
tried. 

Phenolphthalein, in 14 to 1 grain doses, may prove efficacious 
if other remedies fail. 

DILATATION OF THE COLON.^ 

Synonyms. — Congenital idiopathic dilatation of the colon; 
Hirschprmig's disease; giant colon; My^a^s disease; mega colon. 

Etiology. — This is a congenital condition. Those cases de- 
scribed in adult life (pseudomega colon) are believed to be de- 
layed development of the congenital type or another condition 
entirely, due to aggravated constipation. 

A number of theories have been advanced as to the etiology 
of this condition, none of which are convincing. The following 
have been suggested as causes: A neuropathic dilatation and 
hypertrophy; increased length of the colon; a valve formation 
in the intestine; spastic contraction of the sphincter ani; ab- 
normally long mesentery of the colon; chronic colitis, etc., etc. 
Boys seem more often affected. 



] I am indebted to the excellent article of Dr. J. M. T. Finnev, upon this subiect 
in 'Surgery, Gynecology and Obstetrics, June, 1908, for much data in this section. 



DISEASES OF THE DIGESTIVE SYSTEM. 



283 



Pathology. — The process in the majority of cases is limited to 
the sigmoid flexure. The diameter of the dilated portion may 
reach 6 or 8 inches, and it fills most of the cavity. The walls 
show dilatation and hypertrophy. The mesocolon is thickened 
and of irregular lengths. The blood vessels and lymphatics are 













Fig. 50. — Mucosa normal colon. x^OO. 

much dilated. The mucous membrane is thickened, congested 
and occasionally ulcerated. 

Microscopically the mucous membrane shows chronic inflam- 
mation. The circular muscular layer is enormously thickened, 
and the serous coat thickened with enlarged lymphatics and 
blood vessels. 

Symptoms. — Enlargement of the abdomen, the most prominent 
symptom, associated mth obstinate constipation, is present early 
in life. The large abdomen may be noticed at birth, but the 
child may be several months old, perhaps several years before 
the condition becomes very marked. The abdomen is then enor- 
mous, the distension of the colon being due to gas and feces. 
History of a long period between evacuations of the bowels may 
be obtained, one case reported as three months. 



284 



THE DISEASES OF CHILDREN. 



The skin is harsh and dry, complexion pasty, abdominal wall 
thin, through which peristaltic waves can be seen; the veins of 







- •Ptfm.-.nt 't at'^t^c. 













tnucosse 



. <> ^,. A ,■■ 



Fig. 51. — Mucosa giant colon. x 370. 

the skin are distended. Tympanites is quite general over the 
abdomen, the liver dulness decreased. 

The movements from the bowel are apt to be dry or putty 
like, dark in color and offensive. 



DISEASES 0^ THE DIGESTIVE SYSTEM. 



285 




Fig. 52. — Congenital idiopathic dilatation of the colon. 




Fig. 53.1- — Side vieAV of same patient as Fig. 52. 



1 Figs. 50, 51, 52, 53 reproduced through the courtesy of Dr. J. M. T. Finney, 
Baltimore, from Surgery, Gynecology, and Obstetrics. 



286 THE DISEASES OP CHILDREN. 

Dyspnea may, late in the trouble, be quite marked, and bron- 
chitis and pneumonia may be present. Atelectasis may be found 
in the lower portion of the lung. The pulse may be irregular. 
A cone-shaped dilatation of the bladder has been noted. The 
course of these cases is essentially chronic. There is an apa- 
thetic condition. 

Diagnosis. — Meteorism and chronic obstipation are the two 
symptoms practically always present. It must be diagnosed 
from tubercular peritonitis, volvulus, carcinoma of the in- 
testine. 

Prognosis. — ^While not fatal directly, the complications pres- 
ent may bring about death. Pulmonary heart and digestive dis- 
turbances may result fatally. 

Treatment. — This is either surgical or medical. Surgically, 
the following procedures have been suggested: Puncture of the 
intestine (under no conditions to be done) ; colotomy, with evac- 
uation of the contents and closure; colostomy; colopexy; enter- 
oanastomosis ; resection of affected portion and enteroanasto- 
mosis. 

Medically, the following measures have been suggested: 
Cathartics, enemata, massage, electricity, tonics, exercise, diet, 
etc. The mortality rate is given as follows : ' ' Surgical treat- 
ment has a mortality rate two-thirds that obtained by medical 
measures and a recovery rate almost three times as great." 



CHAPTER XIII. 

INTESTINAL PARASITES. 

Intestinal parasites are comparatively infrequent, yet it is a 
common belief among the laity that every child which picks its 
nose or grits its teeth at night is affected with them. Because 
of this deep-rooted belief the subject is of considerable impor- 
tance. Among the facts elicited in regard to the child's history 
is, that it has been given some "worm medicine" before the 
physician has been consulted. 

Intestinal parasites are not seen in very young infants, but 
are found in children after a mixed diet is given, or after it 
crawls around on the floor, putting things in its mouth picked 
up from the floor. 

Varieties. — The following intestinal parasites are found in 
children: the Nematodes; the pin-worm, oxyuris vermicularis, 
whose habitat is chiefly the sigmoid and rectum; the round 
worm, ascaris lumhricoicles, found chiefly in the small intestine, 
and often in the stomach; the hook worm, the ankijlostomum 
duoclenale or toncinaria duodenalis, as the name implies, found 
chiefly in the duodenum; the cestodes, the two species of tape- 
worm, the tenia solium, the pork worm and the tenia mediocan- 
ollata, the beef worm. 

OXYURIS VERMICULARIS. 

Synonyms. — Pin-ivonn; tlireadivorm; seativorm. 

Description. — The habitat of this worm is chiefly in the sig- 
moid and rectum, the female worm, however, being found near 
the cecum. The Avorms and ova are passed in large numbers, in 
the feces and when entangled in masses can be easily seen. In 
girls the vagina may become infected from the discharges. They 
are very small in diameter, the female the longer, about 10 or 
12 mm. in length, the male 5 mm. The ova are quite small, 
symmetrically oval in shape, .05 by .02 mm. in dimension. 

287 



288 



THE DISEASES OF CHILDREN. 



The mode of infection is by means of fingers, toys, frnit in- 
fected with the ova, these being carried to the cecum in the food 
and there develop. They do not need an intermediary host. 

Symptoms. — The chief symptom is the intense itching of the 
anus, produced by the worms in the rectum. The child is very 
restless, both day and night, and is constantly scratching about 
the buttocks. A catarrhal condition of the rectum may ensue. 
If they migrate into the vagina a vulvovaginitis results. Incon- 
tinence of urine may occur from the irritation of the bladder. 
In males an irritation of prepuce may result with swelling and 




Fig. 54. — Eggs of oxyuris vermicularis. 

pain on voiding. The skin about the anus and buttocks shows 
evidence of scratching. 

Diagnosis. — The anus and stools should be inspected in every 
case of pruritus, and if carefully done the worm will often be 
found. An enema should be given and the water returned care- 
fully examined. In every case of masturbation the presence of 
threadworms should be suspected. 

I had under observation a child whom I had previously seen 
in two severe attacks of enterocolitis, with large quantities of 
mucus passed for a long period of time. Upon the first appear- 
ance of mucus in the movements after this, I was notified. In- 
spection of what was thought to be mucus in a movement proved 
to be a mass of threadworms. The diagnosis was verified by 
microscopic examination. In this case the worms had not been 
present long enough to cause any symptoms. 

Treatment. — The chief reliance in the treatment of these cases 
must be had in the use of injections into the colon through a 



INTESTINAL PARASITES. . 289 

long colon tube, as the habitat of the worm is below the cecum. 
The treatment must be thorough or the results will be corre- 
spondingly poor. First, a preliminary dose of ol. ricini, 3ii, 
should be given, and this followed by a high cleansing, saline 
enema, of not less than 3 pints. After this solution has been 
allowed to pass through the tube and with the child on the vessel, 
the tube is reinserted and an injection of 1 ounce of the infusion 
of quassia and 15 ounces of the normal salt solution given high, 
the tube quickly withdrawn, the nates compressed and the child 
kept quiet so this injection will be retained for at least an hour, 
if possible. This treatment is repeated each night for a week, 
at the end of which time a careful examination should be made 
of the stools, microscopically for the presence of ova. 

It should be remembered also that the ova become attached 
to the skin about the anus, and when scratching the fingers of 
the child can become infected, and they in turn carry the ova 
to the mouth, and a reinfection takes place. Hence, extra pre- 
cautions should be taken in cleansing the nates after evacuations, 
and the constant application of a 10 per cent boracic acid oint- 
ment about the anus and skin surrounding. Care must be taken 
also of the napkins, night clothes and bed clothes, boiling after 
each removal. 

ASCARIS LUMBRICOIDES. 

Synonym. — Round Worm. 

Description. — As indicated by its common name, this worm is 
round and smooth, being usually from 4 to 12 inches long, and 
tapering at both ends to a point. This worm is perhaps the one 
most frequently seen in children. The female is nearly twice 
as long as the male, the head having the projections, and pro- 
vided with fine suckers and teeth. The tail of the male is 
turned upward. The ova are round, brownish in color, slightly 
larger than the ova of the threadworm. 

There may be only one worm present, but usually there are 
several. I have had one case in which two were vomited and 88 
passed per rectum. , 

They may be found at any point tributary to the intestine ; in 
the stomach, from which it is usually vomited, at any point in 



290 



THE DISEASES OF CHILDREN. 



either large or small intestine, in the appendix and the gal] 
duct and bladder. They may coil themselves together and form 
a mass of sufficient size to cause an intestinal obstruction. 

Symptoms. — Large numbers of the worms may be present 
and cause no symptoms. The child mentioned which passed 88 
was ill with malaria with high fever, worms were not suspected 
until the first one was vomited. The fever acted as an anthel- 
mintic on the others as they passed from the bowel soon after. 





Fig. 55. — Eggs of ascaris lumbricoides. 

The presence of an eosinophilia has been pointed to as a prom- 
inent symptom. 

The vague symptoms referred to above may be present, but 
they have no significance as a diagnostic aid at all, being caused 
entirely by other pathologic conditions. The first symptom is 
the presence of the worm. The. symptoms believed to be com- 
mon by the laity are restlessness at night, flatulency, picking at 
the nose, grinding the teeth, headache and convulsions. 

Diagnosis. — As intimated, the only reliable diagnostic sign is 
the presence of the worm, either vomited or passed per rectum. 
In this event examination of the feces, microscopically, will re- 
veal the ova in large numbers. 

Treatment. — One of the most reliable vermifuges is santonin. 
It may be given in connection with calomel. 

IJ Santonin 

Hydrargiri chloridi mitis aa gr. i 
Triturate thoroughly. Ft. Cht. No. iv 



These are best given in the morning before breakfast, the 



INTESTINAL PARASITES. 291 

child having had a very light supper the evening j^revious. This 
should be followed by a dose of castor oil (oSs) in four hours. 
On the second day following, the stool should be examined for 
the presence of ova. Toxic effects are sometimes obtained from 
santonin, hence it should always be given in small doses and if 
need be repeated. 

ANKYLOSTOMUM DUODENALE. 

Synonyms. — TJncinaria duodenalis ; hook worm disease. 

Description. — The natural habitat of this worm is in the far 
south countries, but it occurs with fair frequency in this country 
in the Southern States. 

In 1893 Blickhahn ^ reported a case in St. Louis, and in 1898 
Dabney reported a case in New Orleans, and Tebault another 
in the same city a year later. In 1902 Harris claimed that a 
number of cases of anemia in Georgia, Alabama and Florida 
were due not to malaria, as universally believed, but to un- 
cinariasis. 

Stiles states : 1, uncinariasis is pre-eminently a disease of 
sandy localities; 2, infection occurs chiefly in rural districts, 
but this is true simply because it is in such districts that less 
attention is given to the disposal of fecal matter and because 
more people in such localities are brought into contact with the 
soil; 3, whites are more often and more severely infected than 
negroes; 4, infection, as a rule, takes place in more than one 
member of a family ; 5, children and women show a more severe 
infection than men; 6, in hot weather the symptoms of the 
disease are exaggerated. 

The embryos may exist for a month outside the body and de- 
velop in a host. Pollution of the soil from improper disposi- 
tion of the feces is the cause of its dissemination. It is seen 
in dirt eaters; and an infection can occur from uncooked food 
w^hich is taken by the child. The majority of these worms are 
found in the second portion of the small intestine, and are pres- 
ent in large numbers as a rule. 

Symptoms. — The symptoms in the host. of the hook worm are 
believed to be due to a toxemia, chief of which is a profound 
anemia; the subjects are thin and pale, with muddy complexions. 



^ Dock: Loc. cit. 



292 THE DISEASES OF CHILDREN. 

the abdomens protrude and they have no endurance and tire 
easily. There is palpitation and dyspnea, headache and dizzi- 
ness are often present; they are dirt eaters and have perverted 
appetites; have no ability to acquire knowledge or to work. 
They are listless, idle and shiftless. Disobedience, cunning, 
lying, stealing and other symptoms ordinarily attributed to 
hysteria are seen. The bowels are constipated and what is passed 
is often blood stained; the abdomen is often much distended. 
Hemoglobin is reduced out of proportion to the. diminution in 
red cells. Hemic murmurs are heard. 

Diagnosis. — The patient presents a rather typical picture, and 
the diagnosis can be confirmed by microscopic examination of 
the stools for the ova or the parasite can be seen by the eye. 
The ova are much larger than a red blood corpuscle, and have a 
colorless capsule. The parasite is half an inch long, size of 
a hat pin, and one end hooked back on itself. Stiles suggests 
the blotting-paper test for diagnosis, about an ounce of fresh 
feces are placed on a piece of white blotting paper and allowed 
to stand an hour. The feces are then removed and the color 
of the stain examined. In a large percentage of cases of uncin- 
ariasis the color is reddish-brown and reminds one of blood 
stain. This test is not considered reliable. 

A second test is a therapeutic one. Thymol is administered 
and the parasites are found in the stools. 

Prognosis. — This is good if the case has not progressed too 
far and the anemia too profound. 

Treatment. — Snyder ^ recommends a preliminary dose of 
magnesium sulphate. Thymol, finely triturated, is igiven at 
4 p. m. and at 8 a. m. the following morning 'in dose of from 5 
to 20 grains, in capsules, on an empty stomach. This is re- 
peated at 10 'clock and the dose of magnesium sulphate given 
at 12 o'clock. One or two, perhaps more, courses of thymol may 
be needed to control the condition. 

Nourishing food and iron tonics are given too for the anemia, 
one of the best of the latter being diastiron in teaspoonful doses 
after meals. Nux vomica is of service. The children should 
be removed from school. 



Pediatrics, December, 1908. 



INTESTINAL PARASITES. 



293 



OESTODES-TENIA. 

Synonym. — Tape-worm. 

Description. — The life history of the tenia is the ova, the 
larva and the mature worm. The ova are passed from a segment 




Fig. 56. — Eggs of tenia solium. 





Fig, 57. — Head of tenia solium. 
(Magnified eighteen times.) 



Fig. 58. — Head of tenia saginata. 
(Magnified eleven times.) 



of the mature worm, which is found only in man and out with 
the feces. The egg then passes to the alimentary tract of an 
animal (the tenia solium in the hog, the tenia saginata in the 
beef). The egg develops into the larva or embryo which pene- 
trates the intestinal wall by means of its hook-like processes, 
and becomes encysted in the muscle of the host, there to remain 
until set at liberty when eaten by man, where it develops in his 
intestine into the full-developed worm. 



294 THE DISEASES OP CHILDREN. 

The Tenia Solium is shorter than the beef worm, measuring 
from 5 to 15 feet. The segments are shorter and narrower, and 
the head quite small. It is provided with four suckers, and a 
number of hooks. 

The Tenia Saginata or Mediocanellata is from 15 to 30 feet 
long, and consists of segments, thick and yellowish-white in 
color, about an inch in length. They diminish in size toward the 
head, which has four suckers upon it. 

Symptoms. — These are vague and indeterminate. The diag- 
nosis can in the majority of instances only be made by recog- 
nizing the segments in the feces. There may be symptoms of 
indigestion, restless sleeping at night, perhaps some colicky pains. 
Alternating constipation and diarrhea may be present, nausea 
and vomiting may also occur. However, an individual may be 
a host for years and never suspect the presence of the worm 
until a segment has passed. There may be more or less anemia. 

Treatment. — The use of only inspected meat and meat prop- 
erly cooked will serve as an efficient prophylactic. Before treat- 
ment is begun careful instructions must be given that no passage 
from the bowel must be had except on a vessel, so it can be 
closely examined, and the head of the worm found, otherwise 
it could not be told whether the case was cured. 

The child is given a very light supper, and a dose of castor 
oil. Before breakfast the anthelmintic selected is administered, 
among which may be mentioned oleoresin of male fern; pome- 
granate or its alkaloid, pelleterine ; kousso, turpentine and pump- 
kin seed. 

The oleoresin of male fern in 15 minim doses in a gelatin 
capsule if the child can swallow it, otherwise emulsion every 
hour until four doses are taken. This is followed by a dose 
of citrate of magnesia in three hours. 

Pelleterine, while efficient, is too expensive for ordinary use. 
The following prescription is suggested by Townsend : 

I^ Oleoresiu aspidii 5i 

Tincture quillajjTp f.^ss 

Sy)-. aurantii dulcis f.^i 

Syr. aurantii q.s. ad f.5vii 

M. et Sig. Take in two equal doses. 



INTESTINAL PARASITES. 295 

Turpentiue can be taken in an emulsion. 

IJ 01. terebinthinse Siiss 

Aq. Menth. pip Jss 

]\Iucil. tragacanth qs. ^^^ 
M. ft. Emuls. 
Sig. One teaspoonful every three hours, to be followed by one or two 
doses of castor oil a day, in small amounts. 



CHAPTER XIV. 

SURGICAL CONDITIONS OF THE INTESTINES. 

APPENDICITIS. 

Definition. — This is an inflammation of the appendix vermi- 
formis, and under this term, on account of the inability to differ- 
entiate cases clinically, is included all varieties of inflammation 
about the caput coli. 

Etiology. — Typical appendicitis is rarely seen in early in- 
fancy, and but very rarely under five years of age. At this age 
and until puberty the appendix being relatively longer than 
in the adult, and with a larger opening, is more liable to develop 
inflammatory conditions. This allows freer entrance of fecal 
matter which remains, and as a result of bacterial invasion and 
a mild catarrhal inflammation forms the nucleus of an enterolith. 
The younger the child the more the attack differs from one in 
an adult. 

The direct cause is of bacterial origin, the colon bacillus, the 
streptococcus and typhoid bacillus being most frequently re- 
sponsible. The presence of intestinal parasites as an exciting 
cause should be mentioned. The appendix in children is normally 
located higher in the abdomen than in adults. 

In the child subject to that vague condition called lymphatism, 
in which there is a tendency to the enlargement of the lymph 
nodes generally, especially of the tonsils, appendititis is much 
more liable to occur. The rapid progress of appendicitis in 
children has been ascribed to the abundance of lymphoid tissue 
existing in the child's appendix. It has been suggested that 
infection by the bacillus of la grippe or pneumonia is often 
responsible for the lighting up of an acute appendicitis. 

Pathology. — Four forms of appendicitis are clinically de- 
scribed: 1, catarrhal; 2, ulcerative; 3, gangrenous ; 4, sclerotic. 

1. Catarrhal. — In this form the mucous membrane of the 

296 



SURGICAL CONDITIONS OF THE INTESTINES. 297 

appendix is swollen, its lumen being almost if not entirely oblit- 
erated. The process is usually more severe around an enterolith 
if one be present. The mucous membrane exfoliates and the 
cavity is filled with broken-down cells and mucus. The swelling 
is usually more severe at the intestinal opening. After the 
subsidence of the catarrhal inflammation the mucous membrane 
never returns to a normal condition. 

2. TJlcerative. — This is rarely a primary condition, the ulcer- 
ative being grafted on the catarrhal form. The ulcerative proc- 
ess may involve a few small areas or the entire mucous mem- 
brane of the appendix. In those cases of the ulcerative form 
in which there have been two or three attacks, without perfora- 
tion, and which finally subside and apparently get well, there 
remains a constricting band of mucous membrane at the site of 
the most violent ulceration. There may be one spot where the 
ulceration is more severe which may result in a perforation. 
The point where this occurs is near the tip, as a rule, though at 
the site of the enterolith the ulceration may be so severe as to 
result in a perforation. When a perforation of all the coats 
of the appendix occurs, it may result in a general peritonitis 
or the formation of an abscess, w^alled off from the general 
cavity. 

3. Gangf^enous. — In this form the inflammation is so violent 
that a part or the entire appendix sloughs off, causing a general 
peritonitis or a localized abscess, as in the perforative or ulcera- 
tive form. 

4. Sclerotic. — This results from a chronic inflammatory 
process involving a portion or the entire organ. As the inflam- 
mation subsides there is at its site a formation of new con- 
nective tissue which strangulates the normal structure, resulting 
in a replacement by fibrous tissue. 

In all forms but the last there may be a mild localized peri- 
tonitis with the formation of small, fine cobweb adhesions. In 
the latter these adhesions may be present as a result of the pre- 
existing acute process. In the perforative form, without a 
localizing inflammatory wall, a large quantity of pus rapidly 
forms in the cavity. This is usually thin and yellowish, and 
contains lal'ge flakes of plastic lymph or fibrin. 



298 THE DISEASES OF CHILDREN. 

Symptoms. — 1. Catarrhal. In this form there is pain referred 
to the right side of the abdomen, more frequently in the right 
iliac region, but owing to the long mesoappendix in children it 
may be nearer the umbilicus, and not infrequently in the hypo- 
gastric region over the bladder, the epigastrium, or at any point 
from the liver to the iliac fossa. No dependence can be placed on 
the statement of the child regarding abdominal pain in appendi- 
citis. This is associated with tenderness over the site of the 
appendix, and quite early there develops a rigidity of the rectus 
muscle over the affected side, this guard being an involuntary 
manifestation. Rigidity must be differentiated from voluntary 
spasm. It is less apt to be present in the catarrhal form to any 
great extent, but is always present in the other more severe 
forms. There is a slight rise of temperature to 100° or 101° F., 
with quickened pulse and respiration, and vomiting may be a 
prominent symptom. Diarrhea or constipation may be present, 
more often the former. Painful micturition may also be present. 
These symptoms may be so slight as to almost escape notice and 
go entirely unrecognized, being of short duration and not severe, 
and perhaps mistaken for an ordinary attack of colic. 

This was the case in an institution child, nine years old, under my ob- 
servation, wlio liad been ill for a few days with an abscess at the root of 
n tooth, relieved by extraction. Tlie temperature had been normal for two 
days when there was a rise to 102 3/5° F. I was again called, and the 
closest questioning did not elicit any complaint or history which would aid 
in the diagnosis. No complaint had been made to the infirmary nurse. A 
thorough examination was then made, the chest was negative, and on pal- 
pation of the abdomen a distinct mass the size of an egg was found in the 
right iliac region, and an appendiceal abscess diagnosed. This was con- 
curred in by the surgeon, and the child operated upon within four hours. 
An abscess was found containing fully 3 ounces of fetid pus, and with 
great difficulty a perforated and gangrenous appendix was freed from the 
dense adhesions. 

This case is illustrative of the class, and also emphasizes that 
institution children cannot be taken as a guide as they are usually 
stoical and complain much less than children in private families. 

Attacks usually recur with comparative frequency, each one 
likely to be more severe than the former. When there is a his- 
tory of frequent preceding attacks, careful palpation may reveal 



SURGICAL CONDITIONS OF THE INTESTINES. 299 

the congested and swollen appendix through the thin abdominal 
wall. 

2. The ulcerative form, as a rule, presents more acute and 
active symptoms, an exaggeration of those of the catarrhal type. 
The pain is more severe, the patient seems sicker from the 
onset, the temperature may reach 103° F., vomiting is recur- 
rent, great pain being caused by the retching; the tenderness is 
located over the appendix, usually at a point midway between 
the umbilicus and the anterior superior spine, the so-called 
McBurney point. The bowels are more often constipated than 
loose, though a diarrhea may be present. 

This is the description of a classic case, but there are frequent 
anomalies encountered. Because of the atypical cases the diag- 
nosis, sometimes, is most difficult, and again practically no 
symptoms are present calling attention to the abdomen until 
a general perforative peritonitis has developed and the child 
is dangerously sick. 

3. In the perforative form with localization of the abscess 
there is an easily palpable tumor, rigidity of the right rectus 
muscle, high temperature, characteristic attitude, lying upon the 
back with legs drawn up ; hurried, shallow respiration, and rap- 
idly forming and sometimes severe tympanites. The face has 
an anxious expression, and the pulse is small and rapid. There 
may be sweats. 

The blood count will show a marked leucocytosis and this 
may be a decided diagnostic aid. If there is a count of 18,000 
or more leucocytes the diagnosis is usually more certain. A 
steadily-increasing leucocytosis is a more typical picture and a 
w^orse sign than a single examination in which a large increase 
is found. 

Cabot states that mildest and severest cases show no leu- 
cocytosis. Catarrhal appendicitis is rarely accompanied by 
leucocytosis. A low count (8,000 to 11,000) means a mild 
case, a very severe case or an abscess thoroughly walled off. 
When a leucocytosis of 18,000 to 2e5,000 is maintained for a 
number of days, it usually means a large abscess pretty well 
walled off. Bloodgood considers that ' 'within the first 48 hours 
a leucocytosis of 18,000 should be considered an indication for 



300 THE DISEASES OF CHILDREN. 

operation, especially if there is a rising leucocyte count." A 
persistent low leucocyte count is generally a positive indication 
for operative interference when taken into account with the 
other clinical signs. 

The symptoms of the gangrenous form are practically those 
of the ulcerative type, except they are apt to be quicker in 
developing. 

4. Sclerotic appendices present most constant pain, nagging 
in character and are accompanied by more or less digestive dis- 
turbance. Palpation reveals tenderness and slight rigidity. 

Diagnosis. — This, as a rule, is not very difficult, but has to 
be made from a pneumonia, pleurisy^ especially of the lower 
portion, and of the diaphragmatic layer, intussusception and 
volvulus. 

The most frequent mistake in diagnosis would be in mis- 
taking an acute appendicitis of mild type for an acute indi- 
gestion or colic. 

In right-sided pneumonia the characteristic expiratory grunt 
is present, dilation of the alse nasi, redness -of the cheek of the 
affected side, and the characteristic physical signs, as well as a 
much-quickened pulse and respiration in the typical ratio of 
pneumonia, and higher temperature. It must be borne in mind, 
however, that in some cases of central pneumonia there may be 
few of the typical pneumonia symptoms present. Cough may 
be wholly absent. Morse ^ stated that "the abdomen has been 
twice opened in children by well-known Boston surgeons for 
appendicitis, when the trouble was lobar pneumonia. ' ' 

Examination of the chest should be made in every case of 
suspected appendicitis in a child, and in cases of grave doubt, 
wait until developments clear up the diagnosis. 

In a diaphragmatic pleurisy there may be more difficulty in 
making a diagnosis as the physical signs of pleurisy are 
masked, the pain is apt to be referred downward, and there 
may be slight rigidity of the right rectus muscle. The restricted 
freedom of movement of the chest is one of the chief signs. 

In intussusception the early presence of the tumor, which is 
movable, the associated vomiting, of stercoraeeous type if ob- 
struction is complete; the passage of bloody mucus, and without 

1 American Gynecology and Pediatrics, vol. 13, p. 143, 1900. 



SURGICAL CONDITIONS OP THE INTESTINES. 301 

much fever, is sufficient to make the diagnosis of this condition. 
The tumor of an intussusception may be felt by a rectal 
examination. 

Prognosis. — Even if of a mild catarrhal type attacks are apt 
to be recurrent. Age is an important factor. The prognosis 
is graver the younger the child and the more severe the type 
encountered. In the acute perforative and gangrenous type it 
is especially bad and a guarded prognosis should be given in 
every case. 

Treatment. — In no case of appendicitis should the pediatrist 
conduct the case without the advice of a surgeon who, in justice 
to all concerned, should be called early. The disease is essen- 
tially a surgical one, and in the majority of cases an operation 
is indicated. 

If appendicitis is even suspected, the child must be put to 
bed, put on a starvation diet for a few hours, and an ice bag 
applied to the abdomen. An enema should be given promptly. 
Opiates should not be given as they mask the symptoms and ren- 
der later and more positive diagnosis difficult. 

If the ulcerative type can be diagnosed, an operation should 
be performed early. Kelly gives the following reasons for the 
early operation, during the first 24 hours: ''It is safest, the 
operation is more easily done, the patient is spared days of 
suffering; the liability to recurrent attacks and the risk of 
hernia are obviated." 

Richardson ^ states ' ' that the appendix should be removed in 
( 1 ) , all severe cases seen early,- unless there are contraindications 
to operation in other organs or in the patient's general condi- 
tion; (2), in all severe cases which when first seen are at a stand- 
still or are increasing in severity; (3), in all cases in which the 
symptoms are well marked and well localized; (4), in all severe 
cases unless they are unmistakably improving; (5), in those cases 
in which the disease is limited to the appendix itself, and it is 
presumably certain the abdomen can be closed without 
drainage. ' ' 

If more than 24 hours has elapsed since the initial symptoms 
the operation- had perhaps best be postponed until later. 



* Park's Surgery. 



302 THE DISEASES OP CHILDREN. 

The interval operation is indicated in recurrent cases, the 
mortality in these being nil. 

The operation in a child is usually easier than in an adult. 
The muscles are thinner in the abdominal wall and anesthesia 
relaxation easier produced. The operation should always be 
quickly performed, as the time element in the production of 
the shock is very great. Because of the need of stimulation, 
ether is the best anesthetic to be used. Care in its administra- 
tion is more necessary than in adults. 

Because of the various locations of the appendix in the child, 
no special incision can be selected for all cases; it should be 
made long enough primarily in order not to be obliged to lose 
time by enlarging it later. Some discretion is necessary in de- 
ciding whether to drain, to prolong the operation looking for 
the appendix in gangrenous cases, etc. 

Postoperative temperature is the rule for a day or two. To 
combat the thirst, saline enemas every four hours should be 
given in amounts which it is found the child will retain, and 
water by the mouth as soon as there is no nausea. Liquid nour- 
ishment is given early. 

Opium can be given for great pain and restlessness. Bromides 
may be used in the less severe cases. 

INTUSSUSCEPTION. 

This condition is an obstruction of the bowel due to the slip- 
ping of one segment of the bowel into another. When one sees 
the large number of postmortem intussusceptions in one case, 
it is a wonder it is not more often encountered in the living. 
Frequently as much as 10 or 15 inches of the small gut will be 
found invaginated at the autopsy, there being often a number 
of these, and the invaginations are easily reduced. 

Pathology. — The invagination is from above downward, in 
the direction of the fecal current. There are three layers of 
bowel at the tumor, the outer, invaginating, covering or re- 
ceiving layer is the iniussuscipiens, the inner layer the intus- 
suscepium. The narrow, constricted end is the neck. The neck 
is very frequently the ileocecal valve, and several feet of the 
ileum may pass through the neck into the colon. 



SURGICAL CONDITIONS OF THE INTESTINES. 303 

Etiology. — Two theories of the cause have been presented, the 
theory of spasm and of paralysis. 

Wallace ^ suggests that a portion of the bowel is damaged by 
some interference with its blood supply and bulges and may 
perforate, and that the intussusception is the result of nature's 
effort to reinforce the weak piece by splinting it between healthy 
layers of intestinal wall, and that instead of being the cause of 
the trouble the invagination supports the weakened intestine. 

It is more apt to occur during an attack of acute intestinal 
disorders when peristalsis is most active. The relatively long 
mesentery of the bowel in infancy and the thinness of the bowel 
wall has been given as a cause. It is rarely seen in early in- 
fancy, being most frequent from the sixth month to the second 
year, and quite rarely after this period. In a large percentage 
of cases the invagination occurs at the ileocecal valve, the small 
intestine slipping into the colon, the large intestine literally 
swallowing the small, though many occur in the small intestine. 
It occurs more often in boys, in the ratio of about two to one. 

Quite rarely the reverse of the above is seen, where the intus- 
susception will be a segment of bowel from below, telescoping 
into the intussuscipiens above. If much of the bowel is in- 
vaginated owing to the mesentery being attached, the tumor 
is curved on itself, because the mesentery attached to the bowel 
is pulled in after it. 

Owing to the constriction at the neck and engorgement of the 
intussusceptum, pathological changes occur quickly, but the ex- 
tent of these depend upon the length of time which the condition 
has existed. If it has existed for some time reduction may be 
impossible, both from the adhesions formed and the greater en- 
gorgement of the apex of the intussusception. Only one thing 
can occur, if enough time elapses, viz., sloughing of the intus- 
susceptum at its most constricted portion. Adhesions form be- 
tween the invaginated layers, and as inflammation of the peri- 
toneum progresses adhesions of coils of the bowels may occur 
externally. 

Symptoms. — The onset is usually sudden, and if much of the 
bowel is invaginated and sudden constriction occurs, the onset 



Journal American Medical Association, April 11, 1908. 



304 THE DISEASES OF CHILDREN. 

may be associated with some shock. Pain is a prominent symp- 
tom, sudden and violent. The child cries out, draws up its 
legs and vomiting shortly begins. Distension of the abdomen 
is soon noted and the child will soon pass blood and mucus 
from the rectum. The first evacuation may be fecal, but it is 
soon followed by blood and mucus. This is one of the char- 
acteristic symptoms. There is usually no fever at the onset, in 
fact the temperature may be subnormal, and its elevation indi- 
cates beginning peritonitis, but the respiration and pulse, 
especially the latter, are accelerated. If obstruction is complete 
the vomiting may soon become stercoraceous in character, us- 
ually not occurring, however, until late. Later, as peritonitis 
develops there is a rise of several degrees in the temperature. 

The child has an anxious expression, in fact looks sick. The 
presence of a tumor in the abdomen is convincing proof of the 
condition. Through the thin abdominal wall of the child this 
can usually be found, unless the tympany has been too rapid in 
forming. As the intussusception is so often found at the ileo- 
cecal valve, the tumor is most often to be found on the right side 
of the abdomen between the right iliac region and the right 
hypochondrium. The tumor is doughy to the touch, is sausage- 
shaped and rounded. The child may be so sensitive as to make 
palpation of the abdomen impossible. In many cases the tumor 
or intussusception can be felt through the rectum, especially if 
the invagination is in the sigmoid. Hiccough may be present 
and is an unfavorable sign. 

The duration of the attack varies greatly. The attack ma}^ 
be so acute as to be fatal in 24 hours, unless the diagnosis is 
made early and the condition relieved. Other cases may run 
on for four or five days, and one unusual case has been reported 
by Snow ^ of Buffalo in which a seven-months '-old child suffered 
from an intussusception for 16 days, when a piece of gangrenous 
intestine 6 inches in length protruded from the rectum, was 
ligated and removed, recovery following. 

Diagnosis. — The chief diagnostic points are the sudden onset^ 
great pain, acute obstruction of the bowel, bloody-mucous evac- 
uations, the presence of the tumor in the abdomen, absence of 



^ Carr : Practice of Pediatrics. 



SURGICAL CONDITIONS OF THE INTESTINES. 305 

fever at the beginning, the continuous vomiting and the 
tympany. 

There is a train of symptoms not seen in any other condition, 
but even with the association of a few of them, an intussuscep- 
tion should be suspected, and in a child this suspicion becomes 
verified if a sausage tumor is felt in the belly or the invaginated 
gut palpated per rectum. 

Prognosis. — This is necessarily grave, the mortality being 
over 60 per cent in a number of cases reported by different ob- 
servers. Prompt operative interference offers good results. 
Temporizing by trying this or that mechanical means of reduc- 
tion renders the prognosis less favorable, if operation is finally 
resorted to. Chronic cases, because of adhesions, render the 
operation very difficult. 

Spontaneous cures by sloughing off of the intussusception have 
been recorded but they are rare, and cases should never be 
neglected by waiting for this result. 

Treatment. — The only safe and satisfactory method of treat- 
ment is surgical; a laparotomy and reduction of the intus- 
susception by slipping out the invaginated portion of the gut. 
The earlier this is done the more satisfactory the results. The 
longer the operation is delayed the more dangerous it becomes 
and the more difficult the reduction because of the adhesions 
formed between the layers of the gut. Reduction may be impos- 
sible, rendering resection of the bowel imperative. This is nec- 
essarily a very serious operation in an infant. 

Owing to the tendency for the invagination to recur at the 
same site after reduction, the mesentery should be shortened at 
the time of operation. Chloroform should be the anesthetic of 
choice during operation. 

Palliative methods of treatment offer less than the operative, 
promising practically nothing. The ones recommended are the 
inflation of the bowel by gas, and the injection of water, the 
patient being inverted during both of these treatments. I do 
not think they should he used, under any conditions. 

The injection of air can be accomplished through a large 
catheter or rectal tube by a bicycle or automobile tire pump, 
great care and gentleness being exercised. If water is used it 



306 THE DISEASES OF CHILDREN. 

can be injected through the same catheter or tube, the fountain 
syringe being held 4 or 5 feet above the patient, and 3 or 4 
quarts of water used at an injection. The hand should be held 
upon the tumor during this treatment so that the reduction of 
the intussusception can be ascertained. 

If reduction is perchance accomplished, the child must not 
be fed for 8 or 10 hours, kept in partly-inverted position, and 
under the influence of an opiate for at least two days. 



CHAPTER XV. 

GENERAL DISEASES. 

TYPHOID FEVER. 

Synonym. — Enteric fever. 

Definition. — An acute, infectious, febrile disease due to the 
entrance into the body of the bacillus of Eberth. 

Etiology. — The disease is due to the bacillus of Eberth, which 
is taken in the body through the stomach, in food or drink, 
usually either water or milk. Infected dishes or spoons may con- 
vey the bacillus, or the hands contaminated by the discharges 
from the bowel or kidneys of a patient with typhoid may carry 
them to the mouth. 

In 638 epidemics of typhoid fever 17 per cent were due to 
contaminated milk, as reported in ''Milk in Its Relation to Pub- 
lic Health." This reports 138 epidemics traceable to a specific 
pollution of the milk. 

The number of cases of typhoid fever occurring in the camps 
during the Spanish-American War called attention to the fly 
as a disseminator of the contagion in a very practical and serious 
manner. Levy believes the bacilli can enter the body through 
dust. The " typhoid carrier," an individual who apparently 
well, harbors virulent typhoid bacilli, may cause many cases. 

Age. — The infrequency of typhoid in infancy is due to the 
number of breast-fed infants ; when put on artificial food the 
chance of contagion is greater. I have seen one case of typhoid 
develop in a breast-fed infant six months old, who was weaned 
because of typhoid in the mother; the attack in the infant be- 
ginning in the third week of the mother 's illness. 

Dividing the first 15 years into equal parts the far greater 
number of cases of typhoid occur during the last period, the 
least during the first, though it is not infrequent after the 
second year. 

In this section of the country, and along the valleys, it occurs 

307 



308 THE DISEASES OF CHILDREN. 

more frequently during the late summer and fall months. A 
prevalence of typhoid is always expected following the first rains 
after a prolonged drouth where the water supply is not filtered 
or boiled. 

Bacteriology. — Eberth first described the bacillus of typhoid 
fever in 1880. It is a small, short organism with rounded ends 
and very motile, with numerous flagelli, the latter being stained 
by Loeffler's method. It is both saprophytic and parasitic. They 
grow at room temperature, and are killed at 60° C. They are 
very hardy, cold does not affect them, and they live from 7 to 
10 weeks on articles of clothing or other objects. They grow 
readily and characteristically upon acid potato, bouillon and 
milk. 

They are thrown off from the body in the discharge from 
the bowel and kidneys, both of which may cause a dissemina- 
tion of the disease. 

Pathology. — The bacilli gain entrance to the body through the 
mouth, and because of their resistant nature are not harmed 
by the acid juices of the stomach, passing into the intestine, and 
find lodgement in the agminated glands or Pyer's patches. The 
bacilli propagate in these glands, and as a result there is an 
increase in the number of cells, the gland undergoing a regular 
pathologic change, swelling, necrosis, ulceration and cicatriza- 
tion. From the Pyer's patches the bacilli enter the lymphatic 
and general blood circulation, and are found early in the disease 
in the mesenteric glands, spleen and blood current, the kidneys 
and skin. 

Autopsy findings in the very young differ some from those 
in older children, in that the ulceration is not so great in in- 
fancy. The process in older children is similar to that in adults. 

There is decided enlargement and some softening of the mes- 
enteric lymph glands, and an enlargement of the spleen. The 
spleen can practically always be palpated in typhoid, as it is 
quite perceptibly softened and enlarged. The kidneys usually 
show cloudy swelling. 

Symptoms. — My experience has been to find that, as a rule, 
typhoid fever in children is milder, of shorter duration and 
fewer complications than in adults. 



GENERAL DISEASES. 309 

Period of Incubation. — The onset is usually gradual, though 
it is not at all infrequent for the attack to be explosive in its 
onset, with vomiting and fever, the child being apparently en- 
tirely well previously. During the period of incubation it is 
apt to be droopy, not inclined to play or be amused; if old 
enough complains of headache and loss of appetite. There may 
be a slight rise of temperature at this time, but it is usually 
not taken until the child is believed to be sick. Not infre- 
cjuently there seems to be an overwhelming of the nervous sys- 
tem by the toxins, the symptoms at first resembling meningitis. 

Period of Fever. — The typical fever curve of the adult type of 
typhoid is not always seen in children, especially those cases 
of the explosive type or which begin with a chill. In these the 
temperature is high from the onset. The temperature may be 
found to rise gradually, with morning remissions and evening 
rise, each day, both the morning and evening record, being 
higher than the previous day, until the second week, when the 
temperature rises to about the same line each afternoon, with 
a degree or two morning remission. The maximum evening 
temperature is usually not much over 10i° F., though it may go 
higher. 

During the third week there is a gradual fall, the morning 
temperature not infrequently reaching normal by the eighteenth 
day. The division of these fever periods into weeks is an en- 
tirely arbitrary one, representing more the stages, the rise, the 
continuously high fever, and the drop by lysis, than division 
into the seven days constituting a week. 

Hyperpyrexia is infrequent. A sudden drop in the tempera- 
ture to normal or below is alarming, pointing usually to a hemor- 
rhage from a Pyer's patch. 

The pulse increases in frequency as the fever rises, but is usu- 
ally faster than would be expected. As the temperature falls 
during the third week, the pulse is apt to be dicrotic. 

The tongue does not show as marked change as in the adult. 
It is coated from the beginning but rarely is as dry as in adult 
typhoid. The coat becomes more marked in the center and the 
edges red. The mouth is dry and often ulcerated. 

The stomach in the beginning may be upset. Early vomiting 



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GENERAL DISEASES. ' 311 

is not infrequent, but later is exceptional. The hoivels are dis- 
tended after the first week. Tympanites is not marked until the 
second or third week. There may be diarrhea, but constipation 
is very often present. If diarrhea is present "pea-soup" dis- 
charges are the rule. It is very frequent that enemas must be 
given regularly to obtain evacuations. Nosebleed occurs less 
frequently in children. 

. The eruption of the rose-colored spots appears early in the 
second week, and is seen in practically all cases. They are gen- 
erally on the skin of the abdomen, though they may be found 
on any part of the body. These spots are small, papular, slightly 
raised and disappear on pressure. I have never failed to find 
them when they were looked for carefully. 

Headache is not a prominent symptom after the first week, 
though restlessness may be a feature after this time. The head- 
ache at first is often very severe and suggestive of meningitis. 
Stupor and delirium are frequently seen in children, the latter 
being of the low, muttering type, with picking at the bed 
clothes or imaginary objects frequent. 

There is a reduction in the number of both the red and white 
hlood cells, the reduction being much greater after a hemor- 
rhage. There is a coincident decrease in the hemoglobin. The 
^Yidal reaction is present early in the second week. This is a 
typical reaction and is due to the production of a substance in 
the blood, which when added to a solution containing active 
typhoid bacilli causes them to cease moving and to form in 
clumps. The urine is diminished in quantity, and during the 
height of the fever high-colored and of high specific gravity. The 
toxicity of the urine is increased. When the kidneys are in- 
vaded by the bacilli, an inflammatory process is set up, mani- 
fested by albumin, hyaline and granular casts. This is a com- 
plication and not seen in every case. 

The diazo reaction is present in a large percentage of cases, 
and somewhat earlier than the Widal test — probably as early 
as the last of the first week. 

In inflammatory conditions of the kidney due to the ])resence 
of the bacilli, the organisms can be found in the urine. 

The lymph nodes are enlarged and can be palpated in the 



312 



THE DISEASES OF CHILDREN. 



neck, axilla and groin, though they do not reach the size of 
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ble throughout most of the attack. 

Complications. — Hemorrhage is seen less often in children 
than adults. It occurs usually at the end of the second or begin- 
ning of the third week. I have observed hemorrhages but twice 



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Fig. 60. — Typhoid fever; hemorrhage; perforation. 

in children. A hemorrhage is very regularly followed by a drop 
in the temperature of from 3° to 5° F., a corresponding increase 
in the pulse rate and acute anemia and prostration. 

Perforation occurs more often in the hemorrhagic cases. Its 
occurrence is associated with sudden and acute pain, and prob- 
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cided sjanptoras which are always present. Peritonitis follows 
a perforation in a short time, shock is usually present, and a 
fatal termination prompt. In the only case which has com(3 
under my observation the following history presented : 

Boy, aged 13, irregular temperature for one week, continuously between 
101° and 103° F. after the sixth day; first spots noted on the twelfth 



GENERAL DISEASES. 313 

and thirteenth days. Active delirium from the seventeenth day, with great 
restlessness; nosebleed on twenty-second day, with hemorrhage from the 
bowel on the twenty-third day, and a very large intestinal hemorrhage on 
the twenty-fourth day. Temperature chart from the twenty-third day until 
death is given. Twenty-sixth day the pulse was 130 and very weak; twenty- 
seventh, vomits nourishment; thirtieth day, rational at times and com- 
plains constantly of pain in his abdomen; thirty-first day completely deaf; 
death on the thirty-second day of his illness. Postmortem showed general 
peritonitis, fluid in pelvis, bowel covered with thick layers of plastic lymph; 
one perforation, punched out in appearance, one-fourth inch in diameter, 
about 10 inches from the cecum; no adhesions about perforation. 

Bronchitis is a frequent complication and a bronchopneu- 
monia not uncommon. The occurrence of a rapid respiration, 
slightly higher temperature and cough is sufficient to cause the 
respiratory organs to be suspected. The 'bronchopneumonia is 
hypostatic in character and occurs as a late complication, while 
bronchitis is seen earlier. 

Chorea may develop late in the attack or during convalescence. 
Reports of melancholia and mania have been made as complica- 
tions of typhoid fever. 

Otitis media, due to the direct infection of the middle ear 
by the bacillus, occurs in a small percentage of cases. It is 
usually mild, and tends to recovery without complications. 

Aphasia is an infrequent complication, but a very striking 
one. The following case is illustrative: 

Lucile M., aged five and a half years, the only child of a young mother. 
She was spoiled and petted, and was taken rather suddenly ill the first 
week in January, 1906. Typhoid fever was early suspected by the attend- 
ing physician, but the diagnosis was not confirmed until January 8, when 
the rose spots were first discovered. It was entirely impossible for the 
child to be controlled at the home of her parents, and she was removed 
to the residence of a relative of whom she was very fond. Every member 
of the family was ostracised, and the child put in the entire charge of a 
day and a night nurse. 

It is difficult to adequately convey tlie impression of tlio kind of patient 
wc had to deal with in tliis Jitth' girl. She was wilful, ])(>('vis]i. |M^tulaiit. 
cnjss, defiant and extremely diflicult to control. From tlie lemperatmo 
chart exhibited it can be seen that the course of her attack was moderately 
severe. The maximum temperature was 105° F., reached on the thirteenth 
and fourteenth of January, the seventh and eighth days of her attack. The 
impression of the toxins on the central nervous system was quite profound. 



314 THE DISEASES OF CHILDREN. 

there being delirium, involuntary passages from both bowel and bladder, 
and muttering talk. On the seventeenth day there was difficulty in swal- 
lowing, but this was of only two or three days' duration. 

Three or four days after the temperature reached normal the child was 
noticed to mumble its words, where her speech previously had been all 
right. She did not articulate plainly enough to be understood. She was 
asked if she wanted a drink of water and seemed frightened when she could 
not reply. From this time for three weeks she did not utter a sound. At 
the end .of this time she was heard to make a sound; in a few minutes 
she mumbled unintelligible words, much as she had done at the beginning 
of the attack. For two or three days this mumbling continued and by 
the end of the week she was talking plainly. She did not have to be taught 
words or their meaning. As soon as she began to articulate she had no 
difficulty in the least in framing sentences. 

Her convalescence from this time was uneventful and rapid. During 
the next winter she attended school for the first time, however, being kept 
out of her class on account of whooping cough and measles for a good por- 
tion of the time, yet she was promoted to the next grade. 

FurunculGsis is often observed in children. Inflammatory 
joint lesions occur during the latter part of the disease or during 
convalescence, and occasionally bony changes, abscess of the 
bones being the most frequent form of trouble. 

Diagnosis. — Diagnosis must be made chiefly from tubercu- 
losis, malaria, gastrointestinal infection, pyelitis, meningitis, sep- 
sis, appendicitis. Among the chief diagnostic points may be 
mentioned the fairly typical temperature, enlarged spleen, 
rose-colored spots and the laboratory methods of diagnosis; 
Ehrlich's diazo reaction and the Widal test. The diazo reaction 
is obtained as follows: T^o solutions are prepared, (1) a satu- 
rated solution of sulphanilic acid in 1000 cc. of water and 50 cc. 
hydrochloric acid; (2) a 0.5 per cent solution of sodium nitrite. 
To 10 cc. of the sulphanilic acid solution in a test tube are 
added 4 drops of the sodium nitrite solution and 10 cc. of the 
suspected urine. These are well shaken, and a layer of am- 
monia floated on the surface. A bright-red ring at the point of 
contact of the two solutions appears if the urine is from a typhoid 
case. A deep-red color should also appear in the fluid and the 
foam when the solution is well shaken. 

The Widal test ^ is made as follows : 

A drop of fresh or dried blood from the ear of the patient is 

^ French : Practice of Medicine. 



GENERAL DISEASES. 315 

diluted with 5, 10 and 25 or more times as much saline solution. 
A drop of fresh, virulent bouillon culture of typhoid bacilli is 
then added to each, thus forming dilutions of 1 :10, 1 -.20 and 
1 :50, respectively. The specimens are immediately exam- 
ined under the microscope in the hanging drop. The typhoid 
culture should be from 18 to 24 hours old and made from a 
stock culture that is known to react readily to the serum test. 
It should be examined in the hanging drop before the serum 
has been added in order to see that it is free from clumping. 
If the bacilli are very numerous, the culture may be diluted 
with salt solution. The agglutination may occur immediately 
or after 10 or 15 minutes. The bacilli appear grouped together 
in irregular tufts of variable size and become motionless. The 
time at which the reaction becomes distinct in the different dilu- 
tions should be recorded. In the dilution of 1 :10 an imme- 
diate agglutination generally takes place. It may occur in a 
dilution of 1 :50, 1 -.100, or even higher. A specially devised 
agglutinometer for making the test without the use of living 
cultures or the microscope may be employed. 

The absence of this reaction throughout a disease may be 
regarded as positive evidence that typhoid fever is not present, 
since it has been found in 97.9 per cent of 4897 cases collected 
by Brill. 

An agglutination of the typhoid bacillus has been obtained 
from the blood of patients suffering with malaria, typhus, mil- 
iary tuberculosis, cerebrospinal meningitis, and other acute in- 
fections, but rarely in a higher dilution than 1 :5. A reaction 
obtained from a dilution of 1 :30 is, therefore, a positive demon- 
stration of typhoid fever in nearly all cases, unless the patient 
has previously passed through the disease, for the blood often 
continues to agglutinate the bacilli for many years after re- 
covery. About half th^ cases do not give a positive reaction 
before the beginning of the second week, and about a third of 
the cases do not give a reaction before the early part of the 
third week. It may appear, on the other hand, as early as the 
fourth or fifth day. Rarely, it is first obtained in a relapse. 

Tuberculosis. There may be some difficulty in differentiating 
this disease from typhoid, and the laboratory aids to diagnosis 



316 THE DISEASES OF CHILDREN. 

may have to be called upon to clear it up. The occurrence of a 
previous pneumonia, pertussis, prolonged bronchitis, emacia- 
tion, etc., is more common in tuberculosis. In tubercular men- 
ingitis the mental symptoms are prominent early and become 
gradually more profound, while in typhoid the meningeal symp- 
toms appear early. 

Malaria in the South may be mistaken for typhoid. The 
presence of the Plasmodium in the blood and the response of the 
condition to quinine are diagnostic points of value. 

Gastrointestinal infection may present symptoms which are 
confusing. Usually the temperature curve is not so high or long 
and the intestinal symptoms are more marked. 

Pyelitis is very apt to be confused. In one of my cases of 
pyelitis, because of the inability to obtain a sample of urine for 
some days, typhoid was strongly suspected, but the diagnosis 
was cleared up as soon as a microscopic examination was made 
of the urine. 

Septic conditions, such as arise in Pott's disease of the spine 
with abscess formation, abscess of the liver, and other deep- 
seated abscesses may be confusing at first. 

Close observation and inspection of the abdomen should make 
the differentiation between appendicitis and typhoid easy. The 
rigidity of the abdomen and tumor with abscess formation is 
quite typical of appendicitis. 

Prognosis. — In uncomplicated cases the prognosis is good. 
The younger the child the more grave the prognosis. Hemor- 
rhagic cases are more often fatal. Griffiths reports a mortality 
of 3 per cent, Abt reports a mortality of 2.9 per cent. Perfora- 
tion is always fatal without operation. The course is milder 
in children and the duration shorter as a rule. 

Treatment. Prophylaxis. — Proper care and disinfection of 
the evacuations and urine of typhoid fever patients would 
greatly lessen the number of cases which are annually seen. In 
the country, wells and cisterns should be carefully ])rotected 
from sewerage and drainage from the house, and removed from 
the outhouses and privies. In cities, unless the city water supply 
is filtered, all water which is given the children should be care- 
fully boiled. Only a certified milk should be used where it is 



GENERAL DISEASES. 317 

obtainable. If a market milk is used the dairy from which it 
comes should be visited and the methods of the dairyman 
learned. Frequent inquiry should be made as to the presence 
of illness on this place, and if these conditions are unsatisfac- 
tory the milk should be Pasteurized or sterilized before being 
used. 

If a case of typhoid occurs in a private family careful and 
explicit directions must be given to other members of the family. 
Crude carbolic acid should be added to the feces before it is 
emptied, and all vessels and utensils used by the patient should 
be used by him exclusively and boiled each day. 

A tub containing a 1 :3000 bichloride of mercury solution or 
a 1 :20 carbolic acid solution should be provided, in which the 
bed linen is soaked before it is washed. It should not be washed 
with the other household linen. Squares of soft cloth or gauze 
should be used instead of handkerchiefs, and these burned when 
soiled. 

Management. — The presence of fever from any cause in a 
child is an indication for it to be kept in bed, but especially so 
when typhoid fever is suspected. The best room in the house 
should be chosen, with bath room and toilet conveniences nearby. 
No matter how young the child it can be kept in bed, and if it 
is put in charge of a nurse who is gentle, yet firm, this can 
be accomplished. It is rare that the youngest patient has to be 
taken up and held. Its position should be frequently changed, 
not allowing it to lie long in any position. It should not be 
allowed to get up to the vessel, but should be taught to use the 
bed pan. No company should be allowed, no one in the room 
but the nurse and mother. 

A bedside record is an essential in the conduct of a typhoid, 
and a temperature chart or tracing just as important. In no 
other way can the run of the fever of a typhoid be so accurately 
kept track of as by the use of the temperature chart. Tempera- 
ture, pulse and respiration should be taken every four hours. 

The child's eyes should be protected from the direct light, 
but the room should be bright and airy, the temperature not 
more than 65° or 70° F. The bed should be comfortable, pushed 
away from the wall so as to be approached from all sides, with 



318 THE DISEASES OF CHILDREN. 

a firm, but not too hard mattress. The mattress should be pro- 
tected by a rubber sheet, but plenty of thicknesses of sheets or 
pads to protect the skin, otherwise a sudamina or heat rash will 
be caused from the rubber sheet. The gown and sheet should 
be kept free from wrinkles at all times. 

A daily general soap and water cleansing bath should be 
given, as nothing so adds to the comfort of the child. This 
should be given irrespective of the baths given for temperature. 
The judicious application of a 50 per cent solution of alcohol 
to the hips and back will prevent bed sores developing. 

The mouth and teeth should be carefully watched and washed 
at frequent intervals. A very pleasant mouth wash is the 
following : 

IJ Glycerine ^iss 

Listerine Jss 

Lemon juice 3ss 
M. ft. Mouth wash. 

The mouth should be rinsed after every feeding and the mouth 
wash used in the interval. 

Diet. — No other phase of the management of typhoid is so 
important and so difficult to control as the feeding of the pa- 
tient. Milk as an exclusive diet in typhoid is not well borne. 
It offers an excellent culture medium for the organisms which 
are found in the intestine with the typhoid bacillus. The same 
objection obtains in the exclusive use of the animal broths also, 
as they do not meet the demands of the nutrition. If milk is 
well borne it should be well diluted, wdth a low fat percentage. 
Frequently a fat-free buttermilk is well borne and relished. It 
may be necessary to peptonize the milk if there are evidences 
that the proteids are causing an irritation. If a diarrhea begins, 
the milk should be withdrawn. Dr. F. W. Werner of Joliet, 
111., recommends strongly the exclusive use of hot, weak tea, 
claiming for the tea that it is bactericidal, and the liuid and 
slightly stimulating effect of the tea are beneficial. 

Food should be liquid and given at regular intervals, and in 
less quantity than in health. Three to four ounces every four 
hours during the day and twice during the night is ample, with 
a liberal amount of water between. 



GENERAL DISEASES. 319 

Cereal decoctions, dextrinized, are well borne, and usually 
taken with a relish. They can be flavored with the broths, beef 
juice or with sherry, if not otherwise well taken. 

The caloric method of feeding in typhoid is attracting much 
attention, emphasis being laid on the carbohydrates to increase 
the nutritive value of the food. 

Stimulation. — Stimulants should never be given as routine, 
but reserved until they are absolutely indicated, as they fre- 
quently are late in the attack. AVhen the heart beat is weak 
and flagging .or dicrotic, alcohol is of decided benefit, especially 
when the second sound of the heart is muffled or weak. Only 
the best bottled-in-bond article of whisky or equally good brandy 
should be selected. Children stand whisky well and respond to 
its effects ciuickly. A half to one teaspoonful well diluted can 
be given to a child of one year for its effect, every three or four 
hours. Digitalis (2 to 5 min.), strophanthus (2 min.), both in 
the form of the tincture; sulphate of strychnine (1/200 gr.) by 
the mouth or hypodermically to a child of two years, or nitro- 
glycerine (1/500 gr.) in emergencies. 

Fever. — ^A temperature below 103° F. does not need any 
special treatment, but when it rises to 103° F. or over it should 
be reduced. Coal-tar antipyretics should never be given, and 
resort must be had to hydrotherapy, which can be administered 
b}^ the sponge, tub or pack. If the child is under two years of 
age it can be put in the tub without trouble, but a tub bath is 
difficult to give to older children without extra assistance. Low- 
ering the child into the water on a sheet stretched across the 
tub will often be of great assistance. The water should be 
warm, 85° or 90° F., and cooled from 5° to 8° by adding cool 
water at the foot of the tub and thoroughly mixing. The bath 
is prolonged for 10 minutes, or a shorter time if there is 
shock or much nervousness and crying. The constant gentle 
friction of the legs, arms and body, avoiding the abdomen, will 
make the bath much more efficient, and a drop of 2° or 3° 
generally results. The application during the bath of a cold, 
wet compress to the child's head is of assistance. 

The sponge bath is often equally as efficient as the tub bath. 
The child is placed between blankets, and first one member and 



320 THE DISEASES OF CHILDREN. 

then another is exposed and bathed with a piece of ganze thor- 
oughly wet, but not dripping, in water of 85° or 90° F., with 
long, slow strokes ; then the back, first gently turning patient on 
the side, and lastly the abdomen and chest. The whole process 
should occupy from 20 to 30 minutes. The pack applied ac- 
cording to Kerley is very efficient. The jacket or pack, long 
enough to reach below the knees, with arm holes, is put on the 
child dry, and with a large sponge the water, at 90° F., is 
mopped on the pack until it is thoroughly wet. As the pack 
dries, fresh water is applied, gradually cooler, and the pack 
continued until the temperature is reduced. The temperature 
of the child should be taken at least half an hour after the bath 
and finding recorded. The drop, as shown on the temperature 
chart, should be indicated by an S, indicating a sponge, or 5, 
for bath. 

Bowels. — As a rule constipation is present during typhoid, 
and much more to be desired than diarrhea. The place which 
intestinal antiseptics occupy in the treatment of typhoid fever 
is a moot one. Personally I never employ them, and my results 
have been as good as my confreres who use them. Enemata of 
saline solution is usuall}^ all that is needed to obtain an action 
from the bowels, and they should be given regularly. An occa- 
sional dose of castor oil is of great benefit or small dose of cas- 
cara, 20 or 30 drops, of any of the aromatic preparations. 

What constitutes a diarrhea is a matter of individual opinion. 
More than three movements, if thin, should be considered ab- 
normal and call for treatment. If thin and containing undi- 
gested food, a preliminary dose of castor oil should be given, 
followed, when it has acted, with bismuth subnitrate (gr. x or 
gr. XV every three hours). Morphia is rarely indicated, but 
may be needed in very small doses. 

Tympanites. — For the dry tongue and tympanites of the third 
week, no drug can take the place of turpentine, both internally 
and locally. It is difficult to give internally to a child, either 
in an emulsion or otherwise, but can be used as a stupe as fol- 
lows : 

B 01. terebinthinae 3i 

01. olivae ^i 



GENERAL DISEASES. 321 

M. Sig. Rub one teaspoonful over the entire abdomen, and place over 
this the hot wet flannel, which should be renewed at half-hour intervals. 

The stupes should be watched closely as there is danger of 
producing strangury if they are kept up too long at a time. 

Internally, turpentine can be given in 3 to 5 drop doses in an 
emulsion flavored with peppermint. 

Hemorrhage. — This is the most alarming of any complication 
which may arise. If the blood passed is black and no perceptible 
impression has been made upon the pulse, no special active treat- 
ment except starvation is required, but if the blood is bright, 
and there is a coincident fall in the temperature and rise in 
pulse rate, active measures are indicated at once. The foot of 
the bed is raised, an ice bag or coil is applied to the abdomen, 
morphine is given hypodermically (gr. 1/60), and all food and 
water is withheld in order to stop the peristalsis. Gelatin by 
the mouth and subcutaneously is of benefit in profuse hemor- 
rhages, and if doubly sterilized, risk from infection from hypo- 
dermic use is lessened. Hypodermatic injection of normal horse 
serum should be tried, also. Feeding is resumed very tenta- 
tively. 

Convalescence. — This is a most important period, especially 
as to diet, and the patient must be constantly curbed and watched 
in order to prevent overdoing and a possible reinfection or re- 
lapse. The diet should continue the same until the tempera- 
ture has been normal a week, except more can be given at a 
time, when the following list can be followed for a child of 
three years or more : 

First Day. To take the place of one liquid feeding, a thick 
gruel of strained oatmeal. 

Second Day. Rice and milk. 

Third Day. Boiled custard. 

Fourth Day. Milk toast, crust cut off. 

Fifth Day. Baked potato, thoroughly mashed. 

Sixth Day. Soft-boiled egg, one feeding rice. 

Seventh Day. Scraped beef, broiled lightly. During first 
part of the second week the same articles can be given, only 
two in one day, and during the latter part more. 



322 THE DISEASES OF CHILDREN, 

RHEUMATISM. 

Synonym. — Rheumatic Fever. 

Etiology. — The specific, cause of rheumatic fever or rheuma- 
tism has not been located, but the clinical symptoms point to 
some cause of an acute infectious nature, and the finding of a 
diplococcus, practically identical, by both Triboulet and Was- 
sermann, is confirmatory of this theory. That it can be due to 
uric acid or lactic acid does not seem probable. 

The association of tonsillitis and pharyngitis with rheuma- 
tism, or these conditions being a manifestation of rheumatism, 
must be borne in mind. 

It is infrequent in infants under two years of age; from this 
to five years the course is very unlike rheumatism in the adult, 
and may go unrecognized. No joint development may be pres- 
ent. In older children the history is much the same as in adults. 

Exposure and fatigue predispose to an attack. Relapses and 
recurrences are frequent. Heredity must be reckoned with. 

Pathology. — All of the serous membranes of the joints and 
of the heart may be affected. There is a congestion and swell- 
ing, with effusion both in the joint and in the surrounding cellu- 
lar tissue. The frequency of involvement of the endocardium 
in children is much greater than in adults. The pericardium 
is not infrequently involved also. The involvement of the heart 
occurs often when there are but few joints involved, and they 
but slightly. The changes in the heart may precede the arthritis. 
The change in the heart is the result of the action of the infective 
cause of the rheumatism, either bacteria or their toxins, chiefly 
affecting the membrane lining the valves. The mitral valve is 
the most frequently involved. As a result of the action of the 
bacteria, a hyperplasia of the tissue takes place with the forma- 
tion of vegetations on the valve. This prevents the free closure 
of the valve, and as a result an obstruction to the flow of the 
blood current or a regurgitation from imperfect closure. 

Symptoms. — These may be so mild as to pass unrecognized. 

The child may complain of vague pains in the joints and limbs, 
which are ordinarily called ' ' growing pains, ' ' but which are not 
infrequently associated with serious and severe heart lesions. 
Hence, any joint pain in a child should not be treated lightly. 



GEXERAL DISEASES. 323 

In typical attacks, of the adult type, there is a chill or rigor, 
followed by an elevation of temperature from 102° to 105° F. 
There is languor and lassitude, followed shortly by pain and 
swelling of the joints. The number of joints affected varies 
greatly, occasionally only one or two of the large joints are 
involved, though all may be swollen and tender. One of the 
large joints, as the knee, and several of the smaller joints may 
be involved at one time. 

It is in those cases with insufficient pain to keep them in 
bed that the most serious involvement of the heart is seen. The 
pulse may be irregular and of less volume and a physical ex- 
amination of the heart reveals the beginning heart lesion. 
Herz's arm test is a good method of learning the functional ca- 
pacity of the heart. The elbow is supported by the hand, and 
with the free hand the wrist of the patient is grasped and the 
child told to make slow flexion of the forearm. The examiner 
does not resist this movement. Extension is then made as 
slowly, the child concentrating his attention to these acts. The 
pulse is then counted and compared with the count made imme- 
diately previous to the test. If the myocardium is not abso- 
lutely sound the pulse rate is slowed and the size and strength of 
the pulse wave lessened. One drop of the tincture of digitalis 
can be given a child of seven years, and if the myocardium 
is not normal there Avill be a difference in the pulse wave and 
rate from that previous to its ingestion. 

Duration. — The acute symptoms usually last from a week to 
10 days, though the pain may continue some time longer. 

Complications. — Tonsillitis occurs with or may precede by a 
few days the acute symptoms of rheumatism. In fact a severe 
attack of tonsillitis may be the only manifestation of rheu- 
matism, and be followed by an endocarditis, hence an attack of 
tonsillitis or pharyngitis should be regarded with suspicion. 

Chorea is closely allied to rheumatism, and may occur during 
the attack or follow it. Close questioning in cases of chorea 
will usually bring out a previous history of rheumatism. 

Suhcutaneous )wduhs occur in the fibrous or connective tissue 
of the skin, from the size of a pin head to a small pea, being 
scattered i:)articularly over the ends of the long bones and the 



324 THE DISEASES OF CHILDREN. 

vertebrae. They may not be visible on superficial inspection, 
but are easily felt on palpation. They are not painful or ten- 
der. No satisfactory explanation has been offered for their 
appearance. Heart changes have been referred to on a previous 
page. 

Various sHn lesions may appear during an attack of rheuma- 
tism. Sudamina and miliaria, the inflammatory form of sud- 
amina, may develop because of the overactive sweat glands 
and the acidity of the secretion. Erythema nodosum is of 
rather frequent occurrence. These nodes .appear principally 
upon the anterior surfaces of the tibia, are the size of a 
bean, discolored usually, and are quite tender on pressure. They 
may persist after the subsidence of the acute pain. They occur 
more frequently in females. Purpura hemorrhagica may be 
present, with petechial spots or larger hemorrhagic subcutaneous 
areas here and there. Herpes and urticaria are uncommon but 
do occur. Peliosis rheiimatica, Schonlein's disease, consists of 
reddish, raised papules, which are purpuric. 

Pulmonary lesions are not uncommon, especially bronchitis 
and bronchopneumonia. They are probably of septic origin. 

The anemia, which is always present to a certain extent, may 
become quite marked, and in the convalescence prove of some 
moment in the ultimate complete recovery. 

Diagnosis. — This is principally from scorbutus, rachitis, ar- 
thritis, of septic, gonory^heal and tuberculous origin, and espe- 
cially in infancy these conditions must be ruled out. 

In a large percentage of cases of scurvy the first diagnosis 
made has been rheumatism, and frequently not until the soften- 
ing of the gums and hemorrhages of the subcutaneous tissue 
and mucous membrane, that the diagnosis of scurvy is made. In 
scurvy without complications there is no fever, which is a prom- 
inent symptom of acute rheumatism. 

The bony changes in rachitis, no fever, head sweats and his- 
tory should aid the diagnosis. 

In septic arthritis and osteomyelitis the general symptoms and 
condition of the patient is much more severe than in rheuma- 
tism, and the lesion more centered in but one or at the most two 
joints at a time. 



GENERAL DISEASES. 325 

Gonorrheal arthritis is not frequent in children, but may 
present sj^mptoms so similar, that without a history of a vagin- 
itis or vulvovaginitis, a diagnosis will not be made until anti- 
rheumatic agencies fail to relieve symptoms. In scarlatinal ar- 
thritis the previous history and the presence of desquamation 
will clear up the diagnosis. 

Prognosis. — As far as the risk to life is concerned the prog- 
nosis is quite good, provided there is no serious involvement of 
the heart. Recurrences are very frequent. A valvular inflam- 
mation may be present without permanent involvement or crip- 
pling of the valve, but owing to the possibility of recurrence, 
with little or no joint symptoms and severe heart involvement, 
the prognosis should be guarded. 

Treatment. — The first positive indication is to put the child 
to bed and keep it at rest until all symptoms have disappeared. 
The diet should be largely liquid at first, with no meats or ani- 
mal broths. Plenty of water should be insisted upon. Milk or 
any food in which it enters should be the chief diet. There are 
no objections to occasional feedings of the cereals, especially if a 
diastase be given afterward. "With the subsidence of the fever, 
meat extracts or broths can be given; finally scraped beef, fowls 
and vegetables. 

The bowels must be carefully regulated, and if possible one 
of the salines given each morning. Sodium phosphate in half 
or full teaspoon doses, well diluted, is of benefit. 

The affected joints are made more comfortable if protected 
by the application of a cotton bandage, without pressure. A 
local application of a lotion suggested by Fuller is of service: 

B Sodium carbonate 5vi 

Laudanum 5! 

Glycerine ^ii 

Water 5ix 
M. et. ft. Sol. 

The application of analgesique balm (Bengue) to the joints 
is also of service in allaying pain; other remedies suggested are 
chloroform liniment and mesotan. 

Internally some form of salicylic acid is positively indicated, 



326 THE DISEASES OF CHILDREN. 

depending* upon the condition of the stomach and its tolerance. 
Fuller also recommends the administration of alkaline reme- 
dies, the formula suggested being as follows: 

li^ Sodii saUcylatis 3i 

Essentia pepsin ( N, F. ) 

Aquae dest. q.s. ad f^ss 
M. ft. Sol. 
Sig. One teaspoonful at a dose at two hours interval, 

Salophen in three to five grain doses is beneficial also. 

Aspirin in 3 to 5 grain doses. Salicin in 3 grain doses. Sali- 
pirin and salophen in 3 to 5 grain doses. 

After the acute symptoms have subsided, one of these prepa- 
rations should be given for a week or more, and the salicylate 
of colchicum, in the form of the Pil. Colchisal (Fougera) is of 
great benefit. 

For the pain and restlessness, opium in some form may be 
indicated, Dover's powder, morphine, codeine or heroin, in ap- 
propriate doses. 

Iron for the anemia in the convalescence is most important, 
and should always be given either alone or with cod liver oil. 
In the event a severe heart lesion develops the application of 
an ice bag to the precordial region is indicated. This allays the 
pain and discomfort of breathing and limits the amount of per- 
manent involvement of the valves. Digitalis should be employed 
only when indicated by failure of compensation, always judi- 
ciously and in as small doses as possible. 

When the patient is allowed to get up flannel underwear or 
a wool and cotton mixture must be worn in winter, and a thin- 
ner cotton underwear in summer, being careful to protect from 
exposure at all times. 

DIABETES MELLITUS. 

Definition. — As in the adult this is a disease characterized by 
a polyuria charged with sugar; thirst accompanied by wasting. 
It is not a frequent condition in children, but is rapidly fatal 
in the majority of cases. 



GENERAL DISEASES. 327 

Frequency. — Out of 3014^ cases 394, or 13 per cent, occurred 
in children under 15 years of age. 

Etiology. — It occurs infrequently before the end of the first 
year and more often between 5 and 10 years. Sex and race 
have little part in the causation, though slightly more females 
were affected, but heredity plays a decided part in it. Trauma, 
falls or blows upon the head have been suggested as a contrib- 
uting cause. Exposure, tuberculosis, the infectious diseases and 
a diet too rich in sugar and starches begun too early have been 
mentioned as causes. 

Wilcox - found excretion of sugar in the urine after the in- 
gestion of from 15 to 20 grains of glucose, and concludes that 
children care for sugar as well if not better than adults. He 
puts the glucose capacity for the first ten years as 30 to 60 
grains. 

Pathology. — Practically nothing of a definite nature is known 
of the pathology of this disease. A nephritis is often present, 
parenchymatous in type. The pancreas shows a variety of 
changes, atrophy or enlargement, and either hard or soft, con- 
gested or normal. Calculus in the pancreatic duct has been 
mentioned. 

Symptoms. — Frequent urination is the principal symptom, 
with progressive and often rapid loss of weight in spite of an 
increase in the appetite. The increase in the thirst is marked. 
Headache may be a prominent symptom and the child may be 
irritable and peevish, and there is usually an odor of acetone 
to the child's breath and secretions. The skin is dry and harsh 
to the feel. Loss of strength is in proportion to the emaciation. 

The urine is abundant, varying from 700 to 7000 cc, in 21 
hours, clear, and of a high specific gravity, and contains sugar 
and frequently albumen. The sugar varies in amount accord- 
ing to the time of day it is examined, lowest at night, highest 
at midday. Hyaline and granular casts are apt to be present, 
and have been considered a forerunner of coma. Acetone, dia- 
cetic acid, oxybutyric acid may be present and are of grave sig- 
nificance. 

The blood shows an increase in sugar. 



1 Wilcox: Archives of Pediatrics, September, 1908. 
^ Log. cit. 



328 THE DISEASES OF CHILDREN". 

The duration in recorded cases varies from four days to two 
years. 

The child which may have been able to retain its urine all 
night begins to have enuresis and requires frequent changing 
both day and night. More urine is passed, usually during the 
day. 

Complications. — Furunculosis frequently occurs, and pruritus 
is quite common. Tuberculosis is given as a common complica- 
tion. Diabetic coma is the usual fatal complication. Its fore- 
runner is the peculiar sweetish acetone odor to the breath, a 
cessation in the restlessness and increased hebetude and tendency 
to prolonged sleep. "When the coma becomes profound its dura- 
tion is very short and a fatal termination prompt. Cyanosis 
follows the irregular breathing which soon sets in, the extremi- 
ties are cold and pulse weak and rapid. 

Diagnosis. — This is not usually made early because of the 
failure to make urinalyses promptly in children's diseases. The 
association of symptoms should cause the condition to be sus- 
pected, viz., increase in the urine, thirst, increased appetite and 
w^asting, and an examination of the urine to be made. 

Prognosis. — This is always grave, as death follows very soon 
after a diagnosis is made. It is one of the most rapidly fatal 
of the diseases of childhood. The progress and course of the 
disease is best learned by the amount of sugar excreted, quantity 
of acids in the urine, the weight and amount of urine passed 
in 24 hours. 

Treatment. — Breast feeding should be encouraged. Endeavor 
to find which form of carbohydrates is best borne. This ia 
learned by frequent urinalyses while the different starches are 
given. The presence of diacetic acid in the urine is an evi- 
dence that more carbohydrate is needed. Modified milk should 
be rich in fat content if no special acidosis is present, and sac- 
charin used instead of the sugar for carbohydrate content. In 
older children, meat, eggs, green vegetables, animal broths and 
meat juices. 

Drugs offer but little hope of amelioration. Codeine sulphate 
is the onl}^ medicinal treatment of value. One of the forms of 
opium can be tried with arsenic. Benzosol in 3 grain doses for 



GENERAL DISEASES. 329 

its effect on the intestine can be given. For the acidosis, the 
bicarbonate of soda is specially indicated. 

TUBERCULOSIS. 

Etiology. — The tubercle bacillus is the active causative agent 
of tuberculosis. Two chief characters of bacilli are described, 
the human and the bovine types. The human type is a rod 
shaped, colorless, acid fast bacillus with rounded ends, and 
slightly bent. The bovine type has blunted ends, is thicker and 
oval in shape. They are resistant to cold but are destroyed by 
heat and sunlight. 

Children of tubercular parents inherit a tendency to tuber- 
culosis. Other contributory causes are adenoids and enlarged 
tonsils; bad hygiene; improper feeding; prolonged illness; over- 
crowding in schools and homes. 

Pathology. — Every organ or tissue of the body is subject to 
the invasion of the tubercle bacillus. These may be localized 
in individual organs or there may be general dissemination of 
them. 

Glands. — A proliferative inflammation takes place in the 
glands of the body, those situated near the most frequent port 
of entry of the infecting organism being the ones most actively 
affected, viz., bronchial, cervical and mesenteric. The bacilli 
are carried through the lymph channels direct to these scaven- 
gers of the body. The following changes may occur in the 
gland: 1. Chronic proliferation of the gland tissue, enlarge- 
ment. 2. Degeneration, cheesy or fibroid. 3. Abscess, break- 
ing down of the gland due to infection with other organisms. 
4. Calcification. 

The tendency in these glands is to hold the infection as a local 
process, and is an evidence of the leucocj^tic fight being waged, 
an attempt of nature to prevent a general infection or an in- 
vasion into more vulnerable areas. 

The frequency of postmortem findings of bronchial lymph 
nodes is significant of the possibility that the tonsils and respii-a- 
tory nuicous membrane are most often the port of entry. 

Intestines. — Tubercular ulceration here is the same as from 
other causes, and but for the surrounding glandular involve- 



330 THE DISEASES OF CHILDREN. 

ment or bacteriological examination would go unrecognized as 
such. The typical tubercle of the mucosa may be found. 

Meninges. — The chief changes in tubercular meningitis are 
to be found at the base along the vessels, though miliary tu- 
bercles may be found scattered over the entire pia. The in- 
flammatory exudate may be quite thick and over the entire brain. 
The younger the child the more severe the inflammation. 

Kidney. — The most frequent form of involvement here is of 
the pelvis of the kidney, the bacilli being easily demonstrated 
in the pus. Care should be taken to differentiate the tubercle 
bacillus from the smegma bacillus, which can be done by a more 
lengthy decolorization period. 

Lungs. — The lesions of tuberculosis in the lungs of the child 
are much like those in the adult. With a predominance of the 
lymph nodes around the bronchi and trachea. The process 
usually begins with a gland as a nucleus, and spreads baseward 
rather than toward the apex as in the adult. 

Port of Entry. — A child being so much closer to the floor or 
ground when walking, and when younger being on the floor at 
play frequently, is much more open to infection from dust, 
infected toys and hands, than an adult. The infection may 
occur through the mucous membrane of the tonsil, even though 
unbroken, or carried directly to the lungs through the bronchi. 

The intestinal mucous membrane may allow the bacilli to enter 
without an abrasion being present, and it has even been stated 
by one observer that pulmonary infection moi^e frequently oc- 
curred from the bacilli gaining entrance through the intestine 
than through the bronchi. That it does so occur is proven be- 
yond doubt. Skin abrasions may allow the entrance of the ba- 
cilli. 

The lesion found may not be any guide to locating the port of 
entry. 

The ingestion of the bacillus in milk is a positive source of 
infection. Infected milk and butter, nipples, toys, the mouth 
in kissing, dirt under the nails, are also conveyers of the ba- 
cilli. 

Frequency. — During the first year less frequent than after- 
ward. Schwer found 14 per cent of the children autopsied be- 



GENERAL DISEASES. 331 

tween 2 and 12 months to be tubercular. Cornet published re- 
sult of analysis or records of Berlin Pathological Institute, which 
showed of 917 children dying between 1876-1891, 22 per cent 
showed tuberculosis ; Still found 35 per cent in 769 postmortems. 
The greater number of deaths occur between two and four years. 
Jacobi and others have reported cases of fetal tuberculosis. 

General Symptoms. — The development of tuberculosis in chil- 
dren may be very insidious. In all forms the child shows a cer- 
tain departure from normal, which is apparent to the careful 
mother or nurse. There is a listlessness or heaviness not ascriba- 
ble to anything else. The appetite is capricious and the disposi- 
tion variable, rather an inclination in sunny temperaments to 
tantrums and moodiness. 

There is a beginning pallor, the flesh loses its firmness and 
the step its elasticity; and if weighed there is an appreciable 
loss in hody weight. 

Unexplained temperatures are frequently found to be due 
to an acutely inflamed ear without much pain, or a beginning 
involvement with tuberculosis. 

^louth breathing is frequently a prominent symptom, from 
a collection of adenoids in the nasopharynx, the tonsils are en- 
larged and the nasopharynx red. Exhaustion is easily produced, 
these cases having but little endurance. They will play vig- 
orously for a short while, but stop suddenly, lying down, per- 
haps, wherever they may be, often complaining of being tired. 

The pulse is not full, usually much quickened and "irrita- 
ble." Eespiration is hurried, especially on the least exertion. 

Anemia is a prominent and early symptom, shown in a decided 
decrease in hemoglobin, and some diminution in the red blood 
cells. Very acute cases show less blood change than the more 
chronic ones. 

Clinical Varieties. — The special symptoms of the numerous 
clinical types of tuberculosis vary according to the region or or- 
gans affected. The general symptoms just enumerated are more 
or less common to all of them. 

Glandular Tuberculosis. (Tubercular Adenitis.) — Tubercu- 
lar enlargement of the bronchial lymph nodes may never be 
recognized clinically, but at autopsy beginning at the bifurcation 



332 THE DISEASES OP CHILDREN. 

of the bronchi the glands are found much enlarged. Cervical 
adenitis is comparatively frequent. To differentiate an adenitis 
of other origin may be difficult. The tubercular gland, however, 
usually enlarges slowlj^ but continuously, without much local dis- 
turbance and with practically no pain on palpation. As the 
deeper glands enlarge they become matted together, perhaps 
become adherent to the skin and form large irregular, nodular 
masses. They may remain quiescent for varying lengths of 
time, ending in caseation or pus formation with discharge of 
the pus through a fistulous opening which may require surgical 
intervention. The subject of surgical removal of tubercular 
glands, especially when about the neck, has been thoroughly dis- 
cussed, with a preponderance of opinion in favor of noninter- 
ference. Dissemination of the local tuberculosis into a general 
miliary tuberculosis has been ascribed to removal of glands of 
the neck. 

Appetite is very changeable, at times good, at others very 
poor. Sweets are usually craved. 

TUBERCULAR MENINGITIS. 

This may be a local manifestation of tuberculosis or a sequel 
to an infection elsewhere. 

Etiology. — This disease is due to a direct invasion of the 
meninges by the tubercle bacillus. The bacilli may. localize in 
the meninges as a primary affection, absorbed, perhaps, from the 
nasal mucous membrane direct; or they may be carried through 
the lymph or blood from tubercular foci elsewhere, the lungs, 
lymph nodes, joints, abdomen, etc. Lack of resistance from 
previous illnesses is usually present as a determining factor. 
There may be a history of previous attacks of enterocolitis, per- 
tussis, bronchitis, bronchopneumonia, the exanthemata, middle- 
ear disease, from which the child never fully recuperated. 

Age is an important factor in the etiology. Children are 
much more often affected, especially between the ages of two and 
ten, the average age being about four years. 

Pathology. — The pathological changes vary greatly. Autopsy 
findings may be very slight in the severe and rapidly fatal cases, 
and the protracted ones may show severe lesions. 



GENERAL DISEASES. 



333 



The hrain may show changes which vary from a few scattered 
grayish tubercles along the vessels in the fissure of Sylvius, to a 
thick, inflammatory exudate over the entire base. The effusion 
may be thin and seropurulent, and extend into the fissures of 
the brain and well up on to the convexity. Accumulation of 
fluid in the ventricles is usually found, distending them fully. 





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Fig. 62. — Temperature for 81 days in child with general tuberculosi 
tubercular meningitis. 



ending in 



The process may extend into the cord. The pia mater is infil- 
trated. 

The lungs may show unresolved areas of pneumonia, perhaps 
with cheesy disintegration, the hroncliial glands are also en- 
larged and some broken cIowtl or softened. The niesentenc 
glands are usually enlarged, perhaps disintegrated or softened. 
The superficial hjmpli nodes may be found enlarged, also the 
tonsils. 

Symptoms. — But few diseases present so varied a picture at 
the onset as tubercular meningitis, and in consequence the diag- 
nosis in the majority of cases is not made during the early 
stages. 



334 THE DISEASES OF CHILDREN. 

The onset is practically always insidious except in a very few 
cases in which convulsions may usher in the attack. For a very 
varying length of time the child is not normal, is listless and 
peevish, not inclined to play, restless at night, no appetite, and 
if old enough may complain of headache. Nausea may be pres- 
ent with slight gastrointestinal disturbance, sufficient to look 
upon it as the cause of the indisposition. There is a slight rise 
of temperature, not much more than 100.5° F., more or less 
continuous and without decided remissions. In one case seen 
in an adjoining city recently, because of the fever, a tentative 
diagnosis had been made of malaria, and later of typhoid fever. 
After a few days the vomiting may be a prominent symptom, 
recurring often and without provocation. Constipation is the 
rule in this stage. 

After a varying length of time, rarely longer than two weeks, 
the signs of acute inflammation take place, and the diagnosis is 
plain. There is a rise in the temperature to 101° F. or 103° F. 
I have not seen the temperature very much above 104° F. in 
this form of meningitis, though 106° F. has often been reported. 
Before this time the patient could be roused, often with diffi- 
culty, but from now on there is more or less deep stupor, from 
which it cannot be roused. It will swallow when liquids are 
placed between the teeth, but later cannot do this. 

At the beginning of this stage, for a brief period usually, the 
characteristic symptom, Cheyne-Stokes' respi^^ation takes place. 
In two of my cases recently, this symptom was present early 
in the inflammatory stage for 24 hours and disappeared, re- 
turning a few hours before death in one of them. 

The pulse is very variable, at times rapid, at others slow, be- 
ing also irregular in volume. 

Vasomotor phenomena are present, alternate flushing and 
blanching of the cheeks, and the tache cerehrale is usually pres- 
ent at this time. 

The abdomen is retracted, as a rule, giving the typical 
''scaphoid belly." The pupils are usually unequally dilated 
and fixed, though they may be equal. The conjunctival reflex 
is absent and a squint may be present. 



GENERAL DISEASES. 335 

There maj^ be general convulsions at this stage, or only slight 
con\Tilsive movements of the facial muscles and the extremities. 
Rigidity of the neck usually develops early, and as the disease 
progresses there may be opisthotonos more or less marked. 

From this time the child develops into the stage of coma; the 
pulse is very rapid, the respirations shallow and irregular, the 
sphincters relaxed. The temperature just before death may 
rise very rapidly, but usually does not. 

Kernig's sign and the Babinski reflex are found in perhaps 
the majority of cases. 

Death, which is inevitable, may be preceded by general con- 
vulsions. 

The duration is very varied, lasting from one to six weeks, 
Avith an average of perhaps three weeks. 

Diagnosis. — The chief aid in the diagnosis of the form of 
meningitis present is a consideration of the previous personal 
and the family history of the child. 

Acute meningitis usually develops suddenly, and all of the 
symptoms are more acute from the onset, shorter in duration, 
and with higher temperature. 

The low, continuous fever is suggestive of typhoid, and in 
suspicious cases the Widal and diazo tests should be made, and 
if still uncertain at the end of the second week, repeated. 

Lumhar puncture may be of great assistance in clearing up 
the diagnosis (see page 516). The fluid is then examined for the 
tubercle bacilli, pneumococci, staphylococci, etc. It usually 
escapes under increased pressure. 

Prognosis. — The positive diagnosis of a case of tubercular 
meningitis is the equivalent of signing the death certificate in 
advance. If a case of meningitis recovers in which the clinical 
diagnosis of the tubercular form has been made, without isola- 
tion of the bacilli in the spinal fluid, the original diagnosis was 
in error. 

Treatment. — This is purely symptomatic, and of no avail as 
far as a cure is concerned. Chloroform for control of the con- 
vulsions, with bromides and chloral ; liquid diet ; ice bag to head 
and spine; stimulants when indicated, absolute quiet, etc. 



336 THE DISEASES OF CHILDREN. 

TUBERCULAR PERITONITIS. 

While comparatively rare, in children, this variety of peri- 
tonitis is seen in children. The bacillus may find original lodg- 
ment in the peritoneum but is more often transported from 
mesenteric lymph nodes or other more remote port of entry. 

Pathology. — Several forms are described, the ulcerating form 
in which the intestines are matted together and adherent, the 
fibrinous form in which the intestines are covered with a thick, 
purulent exudate through which are seen the miliary tubercles, 
and a matting together of the intestines, and the miliary form 
with ascites. There are numerous miliary tubercles scattered 
over the intestine and parietal peritoneum, a serous or sero- 
purulent fluid escapes on incision of the abdomen in which float 
flecks of fibrin. Numerous adhesions are present both of coils 
of the intestines to each other and to the parietal peritoneum. 

Symptoms. — The miliary form with ascites is most frequent 
in children, and the diagnosis is usually not made early because 
of the insidiousness of the onset. There may be a few indefinite 
digestive disturbances with moderate rise of temperature, per- 
haps some pain in the abdomen, followed sooner or later by grad- 
ual enlargement of the abdomen from accumulated fluid. The 
appetite is variable, the bow'els irregular with occasional attacks 
of vomiting. Before the abdomen becomes tense from accumu- 
lated fluid careful examination may reveal nodules and enlarged 
mesenteric glands. Percussion of the abdomen in changed po- 
sition may show the line of fluid, fluctuation can also be obtained. 

Treatment. — Surgery offers the best results in the ascitic form. 
An incision should be made through the abdominal wall, with 
evacuation of the fluid and immediate closure, without drain- 
age. After convalescence from the operation, the patient should 
have fresh air, judicious feeding, quiet, cod liver oil and other 
tonics as indicated. 

With the development of pathologic changes in the lungs 
symptoms referable to this region appear. Cough, without ex- 
pectoration, except in much older children, as the young always 
swallow material raised from the bronchi or trachea. If pleurisy 
is present, there is usually pain and friction sounds over the 



GENERAL DISEASES. 337 

area inYolved, and an examination will show signs peculiar to 
the stage of the degeneration. Bronchial glands may give 
impaired resonance or high-pitched breathing, if constricting 
either or both bronchi. If the process has been engrafted upon 
an nnresolved pnenmonia, the pneumonic signs persist with 
addition of signs of degeneration, localized fine, moist rales, 
with approach to cavernous breathing as breaking down occurs. 
Pulmonary hemorrhage is quite uncommon in children. The 
following history is a typical one of acute tuberculosis in a 
child: 

L. H., nine years old, was first admitted to the Masonic Home -January 
22, 1895, the physician's certificate stating that both parents had died of 
phthisis pulmonalis. 

Examination on admission showed hypertrophied tonsils, necrosed molar 
teeth and a peculiar listless expression. 

For some weeks after admission it was noticed that she was dull and 
apathetic, having little to do with the other children, apparently preferring 
to be alone. She had peculiar, expressionless eyes, with slight divergent 
strabismus of the left one. 

She was admitted to the infirmary on the 14th of Aprils having had a 
chill on the previous day. She was given 9 grains of quinise sulphas, daily 
for five days, after receiving 1 grain of calomel on the first day, with no 
eft'ect upon the temperature. Examination at this time showed her to be 
very anemic and much thinner than on admission. She was content to 
lie quiet for hours, with a vacant stare, but would answer questions in 
monosyllables, never venturing a remark or making her wants known. 

On May 20 the following notes were made : Very pale, much wasting 
since admission; glands of neck, anterior and posterior, submaxillary and 
sublingual markedly enlarged, some to size of hazel nuts, some larger. 
Inguinal glands slightly enlarged to about the size of a pea. Abdomen 
relaxed. Xo mesenteric enlargements made out. Harsh breathing found 
over posterior aspect of chest, otherwise negative. Some faucial congestion 
with tonsillar enlargement. 

Diagnosis of general tuberculosis with, perhaps, beginning tubercular 
meningitis. On May 23 she was seen by the consulting staft', the diagnosis 
of general tuberculosis being concurred in. 

She was put on nourishing diet and tonic treatment. She would not stay 
out of bed, and gradually grew weaker from day to day. 

From June 23 she complained continuously of severe headache, crying 
out with pain. 

On July 1 she had a general convulsion, contractions of flexor muscles 
of arms and legs being present for some time. Both pupils were dilated 
equally. Large doses of potassium bromide were given without effect. 



338 THE DISEASES OF CHILDREN. 

During the night of July 1 she had many general convulsions^ lasting two 
or three minutes. During the morning of the 2nd day she lay in a stupor, 
perfectly relaxed; she coughed considerably; the pupils were equal and the 
pulse regular. She died quietly at 3 p. m. 

Autopsy. On the morning of the next day, 18 hours after death. Eiger 
mortis marked. Body much emaciated. 

Chest. Lungs. Tubercular nodules and patches of tubercles distributed 
over the surface and borders of both lungs. Slight hypostatic congestion. 
Section shows apices thickly studded with tubercular nodules. Bronchial 
glands enlarged and in a state of fibrous degeneration, not cheesy. Most 
marked enlargement of glands at bifurcation of trachea and along primary 
bronchi. No pleural adhesions. Heart and pericardium normal. A lum- 
bricoid worm 6 inches in length was found in the esophagus. 

.4 hdomen. Peritoneum and mesentery thickly studded with tubercles. 
Mesenteric glands enlarged and fibrous. Appendix vermiformis 3 inches 
long, lying in the right iliac region. 

Head. An excess of cerebrospinal fluid on opening calvarium. Dura, 
normal. Brain (macroscopic examination by Dr. Carl Weidner) is large, 
symmetrical. The pia mater is rather firm. It is cloudy, in some portions 
distinctly yellowish, both at the convexity and at the base. At the vertex 
it can be detached without any difficulty. At the base it is markedly 
adherent in places, and especially so at the fissure of Sylvius. These 
adhesions are quite firm. In addition the pia shows some minute whitish- 
yellow, cloudy spots, and similar granules at the base of the anterior lobes, 
also an increased vascularity. Along the superior longitudinal fissure 
there are an unusually large number of Pacchinian granulations. 

The lateral ventricles having been torn open on a level with the corpus 
callosum (in transportation over rough streets after removal) contained 
no fluid. The cavities seemed large. No signs of disease at the large 
basal ganglia. 

The medulla and cerebellum showed nothing abnormal. 

The case is reported principally on account of the interest at- 
tached to it in connection with the temperature chart, a record 
of the 80 days of acute trouble. (Fig. 62.) 

Diagnosis. — ^With the ordinary methods employed diagnosis 
of tuberculosis is at times a most difficult thing. Any contin- 
uous, irregular fever, in a child presenting the symptoms enu- 
merated above, especially anemia, loss of appetite and strength, 
which cannot be otherwise explained, is very suggestive of tuber- 
culosis. This is especially true when there has been a history 
of exposure. I have recently had under my observation a child 
in whom tuberculosis was strongly suspected because of a per- 



GENERAL DISEASES. 339 

sistent temperature which was later found to be due to an in- 
A^olvement of the middle ears. 

The use of tuberculin for diagnostic purposes has recently 
been proven of great service. It can be employed in the form 
of. a subcutaneous injection of the original tuberculin (Koch), 
by the conjunctival or the Calmette method, and by the cutane- 
ous method of von Pirquet. 

In the ophthalmic test the solution used is prepared as follows : 

The tuberculin is precipitated by the addition of 95 per cent 
alcohol to concentrated T. 0., or Tuberculin Original (Koch). 
The precipitate is collected on filter paper and washed with 
70 per cent alcohol until the filtrate runs clear. It is dried in 
vacuo over HoSO^ and afterwards ground into a powder. The 
powder is dissolved in sterile normal saline solution of 1 per 
cent by weight, heated in a water bath and filtered through 
paper. It is diluted as desired and filled into capillary glass 
tubes, which is then sealed and boiled for 10 minutes in a 
water bath. This insures a perfectly sterile solution, being 
instilled into the eye. 

Two solutions are employed in order to avoid unnecessarily 
severe reaction, No. 1 contains 0.5 per cent, and No. 2, 1 per 
cent. The No. 1 solution is used in one eye, and if no reaction 
is obtained in 48 hours No. 2 solution is used in the other eye. 
It is quite possible that the unpleasant effects reported in some 
cases is due to a too strong solution. Brown advises a 1 :250 
solution in one eye and 1 :100 solution in opposite. The method 
of application is as follows : One end of the capillary tube 
holding the solution is passed through the small rubber bulb, 
and a minute portion of both ends is broken off, and the tube 
slipped back into the bulb. The end of the tube from Avhich 
the drop to be expelled is carefully wiped with sterile gauze 
or cotton to remove any spicule of glass. The lower lid is held 
down, and by holding the tube parallel with the eye 1 drop 
from the tube can be squeezed on to the mucous membrane at 
the outer canthus. The lid is so held as to form a sac, the solu- 
tion being evenly distributed over the lid without allowing it 
to overflow on to the cheek. Occasionally a very slight smarting 



340 THE DISEASES OF CHILDREN. 

sensation is complained of, but this is momentary. It is ad- 
visable to warm the tubes to body temperature if they have 
been kept in a cool place. The tested eye should be protected 
from external irritation, rubbing, wind, dust or smoke. 

The reaction described by Calmette is seen on an average 
at about seven hours after the inoculation, though it may be 
delayed for 24 hours or even 48 hours. The first sensation 
is that of a scratchy feeling, lacrimation and redness, to a more 
severe one of severe injection of the conjunctiva apd swelling 
of the lids. A stuffiness of the nostrils on the corresponding side 
accompanied by a slight coryza. Park suggests the following 
classification of reaction : 

Negative : No difference in the color when lower lids are 
pulled down. 

? Doubtful: Slight difference, with redness of caruncle. 

+ Positive: Distinct palpebral and ocular redness, with 
secretion well marked. 

-\--\- Deep injection of entire conjunctiva with edema of lids, 
photophobia and secretion. 

The reaction may continue for a week and gradually subside. 
In a small percentage of cases there is a slight rise in tempera- 
ture, but this is not often high. 

Both eyes should be closely examined before the inoculation 
to be certain there is no redness present. The presence of a 
distinct disease of the eye or lid is a contraindication for its use, 
as conjunctivitis, blepharitis, trachoma, iritis and keratitis. If 
a marked reaction is noted, the conjunctivitis can be controlled 
by the use of a boracic acid solution wash, or a 2 per cent 
cocaine solution with or without a drop of a 1 :1000 solution of 
adrenalin. 

The cutaneous method of diagnosis consists in a scarification 
like an Abrasion for vaccination against smallpox, under the 
drop of tuberculin after the method suggested by von Pirquet. 
Two abrasions are made, about an inch apart, one being used 
for control, the control abrasion being made under a drop of 
50 per cent glycerine and .1 per cent phenol in normal salt 
solution. Koch's original tuberculin is used, diluted with one 



GENERAL DISEASES. 341 

part of a 5 per cent carbol-glycerine solution, and two parts of 
normal saline solution. 

"Wolff- Eisner describes the reaction in the cutaneous test as 
follows: The early reaction occurs in about three hours, be- 
ginning with slight redness which reaches its height in 2^1: hours, 
and has faded largely in 48 hours. In a few hours a papule 
appears, more plainly felt than seen, and in very occasional 
cases a bleb is formed. 

In the late reaction the redness and papule may be delayed 
until the fourth day, or increase gradually until the fourth or 
fifth day, and may persist for three or four weeks. Enlarge- 
ment or tenderness of the glands in the axilla may be present. 
The reaction is described in this form as the normal reaction 
of the tuberculous individual; the late reaction, which may be 
marked strong or unusually strong; the cpiick, but very weak 
and fleeting reaction which may be overlooked. 

The siitautaneous method consists in the injection of 1/10 
mg. of the original tuberculin (Koch). If there is no reaction 
following its initial administration, a second dose may be given 
after a lapse of two or three days, gradually increasing by 1/10 
mg. doses up to 3 or 1 mg. Brown advises giving the injection 
at night, when, in a majority of instances, the reaction occurs 
in 8 to 20 hours. It may occur in four or five. Late reactions, 
second or third day have been noted. On this account the 
injection should be given every third day. A "reaction" is 
evidenced by ''pain, tenderness, redness and swelling at the site 
of the injection, headache, malaise, an increased tendency to 
cough, probably more or less expectoration than usual, and at 
times some gastrointestinal symptoms as nausea and vomiting." 
There may be a rise in temperature also, and if this amounts 
to 2° F. it' is fairly characteristic. 

The Moro reaction is obtained by using a 50 per cent oint- 
ment of tuberculin and lanolin. A piece of this the size of a 
pea is rubbed into the axilla. In 21 or 18 hours, in the presence 
of tuberculosis an eruption of macules and papules appear 
which persist upwards of a week. 

Owing to the unfavorable reports of the ophthalmoreaction. 



342 THE DISExiSES OF CHILDREN. 

which are becoming more numerous, the cutaneous or vaccina- 
tion method is recommended as the most desirable test. 

The laboratory is an aid to diagnosis of this condition in 
children, but owing to the infrequent successful attempts at 
obtaining a sample of sputum, and the difficulty of finding the 
bacilli in the feces, it is not as frequent an aid as might be 
hoped for. By closely examining the blood and mucus in sus- 
pected intestinal tuberculosis the bacilli may be found. In 
malaria or typhoid fever the organism peculiar to these condi- 
tions may be found. 

In tubercular pyelitis and cystitis the bacilli may be isolated. 
The smegma bacillus must be differentiated in the urinary ex- 
amination, the urine being obtained by catheterization per- 
formed in the most aseptic manner. 

Blood examination may show in the early stages an increase 
in the polymorphonuclear cells, later the mononuclears may 
predominate. 

Prevention. — Prevention of tuberculosis in infancy is most 
important. The source of milk supply must be known, and 
only certified milk and inspected butter used. 

A child should never be allowed to come in contact with a 
consumptive, or to visit a house in which it is known there is 
a consumptive. Kissing children in the mouth should never 
be permitted. 

Treatment. — The same general principles of treatment of tu- 
berculosis in children should be instituted as are employed in 
adults. If a sanitarium is possible, it will be found very easy 
to adapt a child to the routine sanitarium life. Children do 
not stand well either a very cold climate or a warm, enervating 
one. Absolute rest in bed, in the open air, should be insisted 
upon at first, and exercise allowed very moderately and care- 
fully. This treatment is indicated in surgical tuberculosis as 
well. 

Children stand forced feeding when properly instituted, very 
well, indeed, milk and eggs, being the best borne for the extra 
diet. Only ''Certified" milk should be given when it is ob- 
tainable, if not the milk should be carefully Pasteurized. 

The original tuberculin is used, the dosage varying accord- 



GENERAL DISEASES. 343 

ing to the patient and its age, 1/12000 to 1/8000 mg. for a child 
of one year of age. 

The beneficial effect of tuberculin could be substantiated by 
a number of reported cases. 

Medication is of secondary importance to a carefully regu- 
lated diet. Tonics undoubtedly have their indication, when 
judiciously employed, especially when there is a failure of 
appetite or a disgust for food. Cod liver oil can frequently be 
taken either pure or in emulsion to great advantage. Iron, the 
carbonate, citrate or muriated tincture, syrup of the iodidC; 
diast iron, will be found of benefit. Preparations of malt may 
often be used to advantage. 

Baths followed by a general rub with olive oil or cod liver 
oil in the poorly nourished are most beneficial remedies. 

The importance of life in the open, especially for those chil- 
dren living in the close quarters of the poorer classes, cannot 
be overestimated. Open air schools for the tubercular child 
or the child who shows a tendency to a tubercular diathesis 
have been most successful. Proper attention to clothing, rest, 
and food for the child in the open air school is necessary for 
good results. 

PELLAGRA.^ {Telle, skin; Agra, rough.) 

This is a disease which prevails in the Southern States, not- 
ably North Carolina, South Carolina, Mississippi, Alabama and 
Texas. 

It is a toxemia, supposed to be directly due to eating damaged 
corn, and is manifested by disorders of the nervous system, di- 
gestive system and localized erythemas of the skin. 

Pellagra has been known since 1755, the first cases occurring 
in Spain, followed by others in Italy, France and Egj^pt. It 
has occurred in South America and Mexico, and in this country 
in Alabama, at the Mt. Vernon Insane Asylum, first reported 
by Dr. Searcy in 1906. Since this time many other cases have 
been seen. 

Etiology. — Eating damaged corn is believed to be the direct 
cause of this disease. Bad hygienic surroundings and insuffi- 

1 1 am indebted to the writings of Dr. Geo. H. Searcy, Tuscaloosa, Ala., for 
much of the data of this chapter. 



344 



THE DISEASES OF CHILDREN. 



cient nourishment of other kinds are contributory causes. Corn 
is usually consumed in the South as cornmeal and grits, and 
these when moulded, contain fungi and bacteria. Searcy likens 
the condition under discussion to gangrenous ergotism, and be- 
lieves the smut (nstilago) resembles the ergot of rye very much, 
and that corn smut is the cause of pellagra. 

The direct action of the sun's rays is believed to be a con- 
tributing cause of the skin lesions of pellagra, these occurring 
chiefly upon the exposed parts of the body. 

Symptoms. — Cases of pellagra are either acute or chronic. 

The first symptoms of the acute form are a marked lassitude 
and weakness, followed by loss of flesh and varied gastrointes- 




Fig. 63. — Pellagrous dermatitis: 



dry form, with exfoliation of the skin. 
Pellagra. ) 



(Roberts: 



tinal symptoms. The duration of this stage may be some weeks. 
The acute symptoms begin by a salivation and symptoms of indi- 
gestion, perhaps pain and tenderness in the epigastric region, 
followed by diarrhea. 

The skin lesions develop about this time, chiefly the exposed 



GENERAL DISEASES. 345 

parts of the body being affected, limited to the extensor surfaces 
of arm and hand, dorsum of feet, face and neck. The lesions 
are symmetrical. The appearance of the skin is a deep red, 
and a decided anesthesia in the part affected. The affected 
skin either forms bullae and blebs or becomes scaly and thick- 
ened. If the vesicles form they rupture and leave a denuded 
area which is moist. The nervous symptoms are soon manifest, 
not so marked in the early acute stage as when the disease be- 
comes chronic. The chief mental symptom is a depression 
which grows more marked if the case becomes chronic. There 
is pain and tenderness in the dorsal region close to the spine, 
with exaggeration of the patellar reflexes. Later the reflexes 
are either lessened or absent. Insomnia is a marked feature 
from the beginning. 

The temperature may be elevated a degree or two, but is 
more often subnormal. 

The acute cases may prove fatal in a few days after they have 
to go to bed ; may lapse into a chronic condition or may recover. 
If recovery takes place the improvement is slo^, taking several 
months to return to normal. 

In the chronic form there may be a history of an acute attack 
shortly before, or, as is more common, an attack during the 
previous summer. The skin, which has been the site of the 
eruption, is thick, wrinkled and scaly. 

The pronounced mental symptoms, depression and melan- 
cholia, usually do not become noticeable for a year or more, but 
as the disease progresses the mental symptoms are so severe as 
to necessitate confinement of the patient in an asylum. Demen- 
tia is the usual final outcome. 

Contractures of fingers and even of arms or legs are common 
late in the disease. 

Diagnosis. — The association of the following symptoms is 
sufficient to make the diagnosis: Location of erythema, vesicles, 
etc., on the extensor surfaces of the exposed parts of the body; 
salivation, stomach disturbances and diarrhea; mental depres- 
sion, and the history of the corn diet. 

Pathology. — Fatty degeneration of the internal organs ; pachy- 
meningitis and degeneration of the posterior nerve roots and 



346 THE DISEASES OF CHILDREN. 

posterior columns of the cord, and in the dorsal region, in the 
lateral columns, and the changes in the skin. There is also 
anemia and emaciation. 

General atrophy of muscles of body and the walls of the 
stomach and intestines take place in the chronic cases. 

Prognosis. — A mortality of 58 per cent was reported at the 
Mt. Vernon Hospital. Death usually occurs within three weeks 
of the time the patient goes to bed. When recovery takes place 
it is slow. 

Treatment. — The principal treatment is dietetic. Remove 
from the list of food all corn in any form. Give animal broths 
and milk. Do not keep the patient in a bright sunlight. 

Medicinally, arsenic is indicated. Searcy recommends it in 
the form of atoxyl, gr. iss doses, once a week hypodermically, 
increasing to 2 grains. 

MALARIA. 

By Wm. Britt Burns.^ 

Synonyms. — Malaria; ague; paludism; intermittent fever; 
paludisme {Fr.) ; Wechsel fieher {Gr.) ; paludismo (It.). 

Definition. — A specific infectious disease, due to the invasion 
of the blood of several species of the hemosporidia of the genus 
Plasmodium malarice. The disease manifests itself, according 
to the species of infecting parasite, in three types, which are 
distinguished in common by the occurrence of periodical, inter- 
mittent or subintrant febrile paroxysms. 

Historical Note. — Contemporaneous writers of ancient times 
chronicle the fact that malaria then existed. We learn from 
the writings of A. Groff that malaria was well known to the 
early Egyptians. The word ''Aat" occurring as an inscription 
on the temple at Denderah, is said to indicate the annual recur- 
ring epidemic. Our knowledge of malaria has been moulded 
for us by the acute observations and fairly accurate accounts 
of the disease by Hippocrates, Galen and Celsus, before the dis- 
covery of Peruvian bark (Cinchona), in 1640. 



1 Dr. Burns while a resident near the swamps of Arkansas did a large amount 
of original work upon the subject of malaria, before taking up, in recent years, a 
general surgical practice in Memphis, Tenn. At the time the work of Ross, Grass! 
and Bastianelli was in progress, Dr. Burns checked it in his observations. Dr. J. 
B. McElroy, of Memphis, has read the manuscript and corrected the proof of this 
chapter. 



GENERAL DISEASES. 347 

With this period are associated the names and work of 
Sydenham, Torti and Morton. Torti and Morton divided the 
''essential fevers" into two classes, namely, those that were cur- 
able by treatment with cinchona bark and those in which it had 
no effect. Lancisi was the first to conjecture a relationship 
between malaria and the telluric, meteorologic and climatic con- 
ditions; also to notice the very dark color of the liver at necrop- 
sies in fatal cases of malaria. In the eighteenth century de 
Haen noticed the rise of temperature during the chill. 

During the latter part of the eighteenth century rapid coloni- 
zation all over the world made the differentiation of malaria 
from other endemic tropical and subtropical diseases difficult 
indeed. The separation was satisfactorily accomplished in the 
nineteenth century. So that this epoch ends with the discovery 
of the malarial parasite by Laveran in 1880. 

The characteristic bodies having been found, the study of the 
mode of infection began to be hypothesized. Nott of Mobile. 
Ala., in 1848 published a paper on yellow fever, and in touch- 
ing on malaria wrote as if the mosquito theory had already been 
advanced. King in Washington in 1883 collected evidence; 
Laveran in 1891; Bignami in 1896 suggested that the moscjuito 
might be the infecting agent. Koch claims to have thought of 
it in 1883-4. But Patrick Manson in 1894, was the first to 
offer argument in support of the ''conjecture" as he called it. 

The third and grand epoch in the advances of our knowledge 
was opened by Surgeon-Major Ronald Ross of the Indian 
Medical Service, who in 1895 began to elucidate and prove Man- 
son's theory, and in September, 1897, after examining a thou- 
sand mosquitoes for both avian and human malaria. The Ital- 
ians, Grassi, Bignami and Bastianelli, in 1898, confirmed the 
work of Ross. 

. Etiology. — The Plasmodium malaria?, the infectious agent, is 
introduced into the human body, by the bite of mosquitoes of 
a certain variety, namely, anophelinae, which have themselves 
been infected by feeding upon individuals, whose blood con- 
tained sexual forms of the malarial parasites. 

The endogenous cycle or schizogony in a new infection be- 
gins with the sporozoites, penetrate healthy red corpuscles. 



348 



THE DISEASES OF CHILDREN. 





Fig. 64. — Anopheles Crucians. Female 
mosquito, greatly enlarged. 



Fig. 65. — Anopheles puncfdpennis. Fe- 
male mosquito, greatly enlarged. 




Fig. 66. — Anopheles quadrimaculatus. 
Female mosquito, greatly enlarged. 





Fig. 67. — Anopheles mosquito at rest. Fig. 68. — Common mosquito at rest. 



Note. — Figs. 64, 65, 66, 67, 68 from article by Dr. S. P. Lathrop, New York 
City, published in June, 1913, Medical Herald. 



GENERAL DISEASES. 349 

barring phagocytosis, becoming trophozoites or ring forms, and 
later schizonts. These bodies feed upon the red cells, con- 
verting their hemoglobin into melanin, reaching their full 
growth; the segmentation stage, or "roset'' form, they divide by 
schizogony into a number of spores or merozoites. The rem- 
nant of the red cell, with its contained pigment, having dis- 
integrated, the merozoites are set free to attack other uninfected 
and occasionally infected red cells. The asexual or schizogonic 
cycle is completed. 

When the parasites are first introduced into the blood, their 
numbers are relatively small, hence for a certain length of time 
no symptoms are produced upon the host, the so-called incuba- 
tion stage, measuring from 6 to 12 days. During this, it is 
said, the schizogonic stage only is reached. About this time 
the reaction of the patient, as in the production of fever, appears 
to stimulate the merozoites to development into the sexual forms, 
namely, the male or microgametocyte, and the female or macro- 
gametocyte. If the host is now bitten by the proper mosquito, 
these sexual forms, with other forms, are taken into its stomach, 
where the remnants of red corpuscles and their contained pig- 
ment and the asexual forms of parasites are digested, etc. The 
male cells put out flagella (microgamete), which, after a 
decided hammering motion, are thrown off, and finding 
the female cells (macrogamete) penetrate and fertilize them. 
The conjugation stage is called the zygote and the next step the 
ookinete. When this is accomplished, the ookinete pushes its way 
into the wall of the mosquito's stomach and begins its growth. 
The oocyst is formed; inside of which is developed, first, spor- 
oblasts; second, sporozoites. The oocyst is seen to be, in size, 
in proportion to the length of time between the feeding and 
deatli of the insect, namely : They nmy reach a greater size, 
according to Stephens. 

7 microns after two days 

17 microns after four days 

19 microns after five days 

25 microns after seven days (Ross) 

The oocyst having reached its full development ruptures, and 
a large number of curved, thread-like bodies, sporozoites, escape 



350 THE DISEASES OF CHILDREN. 

into the surrounding- serum. These bodies are now ready and 
fit to be introduced into the host. On staining, the sporozoites 
contain, centrally located, one or two small masses of nuclear 
matter, and measure 14 microns in length, tapering at either 
end. In the unstained, fresh specimens, they exhibit a decided 
writhing motion. 

Quartan Parasite. — The quartan parasite is smaller than the 
enveloping red cell, when its segmentation stage is reached; it 
causes the red cell to shrink and usually becomes darker in color. 
Its full development is accomplished in 72 hours. 

Beginning with the sporozoite or ring form (hyalin body), 
as a pale, refractory spot in the substance of the red corpuscle, 
usually eccentrically, about 1/10 the size of the containing cell; 
it feeds upon the hemoglobin, converting this into pigment and 
proper tissue. The pigment of the quartan parasite is char- 
acteristic, in that it is darker and in larger blocks or grains 
and lazier, than the pigment seen in the other varieties of 
Plasmodia. Between the hyaline stage and the segmentation 
stage, the different forms are merely larger parasites, wdth more 
and more pigment. The melanaemia of malaria is one of its 
most characteristic features. Tw^o varieties of pigment occur, 
namely, melanin and hemosiderin; the second is found in the 
internal organs and gives the reaction to iron ; the first is found 
in the circulating blood everywhere. The quartan divides into 
from 6 to 10 spores or merozoites. 

The Benign Tertian Parasite. Plasmodium vivax. — The 
growth of the benign tertian parasite is exactly similar to that ob- 
served in the growth of the quartan; it is, however, very much 
more rapidly motile, the pigment is finer and keeps up a dancing 
motion, almost continuously. The containing red cell begins 
to swell early, and it becomes paler in color. The full-grown 
pigment bodies (schizonts) may, by the inexperienced, be taken 
for a pigmented or a granular leucocyte in the fresh blood. 
The segmenting body, both of the tertian and quartan, have the 
appearance of the daisy or marguerite. When the cell ruptures 
the remnant of the cell and its contained pigment are carried 
to the spleen. Segmentation occurs at the end of 48 hours, 
setting free 18 to 20 spores (merozoites). 






.vV'.' .-c^' Ht-' 



I 







^3 :J^ ;^^^ 

PLATE II. 



^7 



zo 



I? 



lyiFE- Cycle of Plasmodium Vivax. 

(AFTER GRASSI AND SCHAUDINX.) 

The human cycle is above the transverse line, some rearranged by Kissalt and Hartmann. 
The cycle in the mosquito is beneath. 1 to 7, Schizogony: 1. sporozoite: 2, entrance of sporozoite: 
3 and 4, growth of the schizont: 5 and (i, nuclear division of the schizont: 7. formation of the mero- 
zoites; 8, merozoites: 9a to 12a, growth of the macrogametocyte: 9b to r2b, growth of micro- 
gametocyte: 13c to 17c, parthenogenesis of the macrogametocyte: 13a and 14a, maturation of 
macrogamete: 13b and 14b, growth of the microgamete: lob, microgamete: Iti. fructification: 17. 
Ookinete: IS to 20, entrance of the Ookinete into the stomach wall of the mostiuito: 20to25. 
sporogony: 22 and 23, nuclear multiplication in the sporont: 24 and 25, formation of the sporozoites: 
26, passage of the sporozoites to the salivary gland: 27, salivary gland of the mosquito with 
sporozoites (Magn. 1 to 17c, 1200 to 1: 18 to 27c, 600 to 1.) Park: Pathogenic Bactei-iaand Protozoa. 



GENERAL DISEASES. 351 

The Estivoautumnal Parasite {Laverania Malarice). — The 
young forms of this variety of malarial parasite are somewhat 
smaller than either of the other forms; not so motile as the 
tertian, and does not show the amount of j^igment of either. 
The full-grown bodies are about the size of the red corpuscle; 
at this stage they show several grains of rather coarse, black 
pigment. The segmenting body is divided rather symmetrically 
into from 8 to 25 merozoites. The sexual forms, ovoicls and 
crescents (gametocytes), develop after a few days of the infec- 
tion. The staining reaction of all of these forms is quite 
characteristic : 

In a suitably stained preparation (using a chromatin dye) the young 
parasite appears to be a disk, consisting of a central, pale, unstained area, 
known as the achromatic zone, and of a basic (blue) periphery, the body, 
including a metachromatically stained, rounded, compact (red), chromatin 
mass, the nucleus, which tends to give the parasite the form of a signet 
ring. Later stages up to a certain number of hours, show simple changes in 
size and outline of the body. The nucleus then divides by simple mitosis. 
Later it breaks up by amitotic division into an increasing number of 
angular pieces. By the time that chromatin division is completed, the 
angular chromatin masses will have assumed a rounded form, and will be 
seen to exhibit ultimately the same strong affinity for certain dyes which 
is seen in the compact chromatin body of the young ring-like form.i^ 

When the parasite undergoes division the merozoites show, 
on staining, a chromatin mass with each achromatic body. The 
best stain is, probably, Leishman's or "Wright's modification of 
Romano wsky's stain (eosinate of oxidized metlndene-blue), 
which is made as follows: 

Leishman's Modification of Eomanowsky's Method.- 

Leishman's method gives good results for general blood work, 
fixing at the same time as it stains. It has also the advantage 
that it stains the red blood corpuscles infected by the malarial 
parasite in a special manner. 

Solution A. One per cent medicinal methylene-blue i^Grub- 
ler) in distilled water; add 0.5 per cent NaoCO^ until alkaline. 



iPark: Pathogenic Bacteria and Protozoa. 

2 British Medical Journal: Methods of Morbid Histology and Clinical Pathologj", 
Walker Hall and Herxheimer. 



352 THE DISEASES OF CHILDREN. 

Heat to 65° C. in paraffin oven for 12 hours; allow to stand 
at room temperature 10 days before use. 

Solution B. Eosin (extra B. A. Grubler), 1 gm. ; distilled 
water, 1000 cc. 

Mix equal volumes of A and B in a large open vessel; allow 
to stand for 6 to 12 hours, stirring occasionally. Collect the 
precipitate on a filter, wash with distilled water until the wash- 
ings become almost colorless, dry and powder the residue. 
(Grubler now makes this dye, and it may be also obtained in 
^'soloid" form from Burroughs, Welcome & Co.) 

To Prepare the Stain. — Dried precipitate (green, metallic 
lustre), 0.3 gm. ; pure methyl alcohol (Merck "for anah^sis"), 
200 cc. 

The solution is of a dark-blue color, shows a greenish iri- 
descence by reflected light, and when kept in stoppered glass 
bottles does not deteriorate. 

Staining. 

1. Prepare a thin film. Dry in the air. 

2. Stain with 4 drops of dye for 30 seconds. 

3. Add to the alcoholic stain 6 or 8 drops of distilled water, 
and allow it to mix with the dye (by rotating the forceps). 

4. Allow the film to stain for 5 minutes (if film is very thick, 
10 minutes). 

5. Wash the stain away with distilled water. Allow a few 
drops of water to rest upon the film for 1 minute. 

6. Dry in air or with blotting paper. Mount in xylol balsam. 
Red. — Neutrophile, or fine eosinophile granules. 

Buhy Red. — Nuclei of polymorphonuclear and mononuclear 
leucocytes. 

Pink. — Red blood corpuscles. Eosinophile granules. 

Violet to Purple. — Basophile granules. 

Pale Blue. — ^Extra nuclear protoplasm of leucocytes and 
lymphocytes. 

Blue. — Plasmodium malariae. Bacteria. 

If the red corpuscles appear bluish instead of pink, the pink 
color may be restored by washing the film in 1 :1500 acetic 
acid solution. Heat may not be used to dry the film, as it 
breaks up the stain and decolorizes the chromatin. 



GENERAL DISEASES. 353 

If a granular deposit is deposited on the films, remove it by 
washing quickly in absolute alcohol, the film, after a few sec- 
onds, being plunged into distilled water to stop the decolorizing 
effect of the alcohol. 

For Schuffner's and Maurer's ''dots" stain with the mixture 
of stain and water for 1 hour, placing the preparation under 
a watch glass or the lid of a petri dish to check evaporation. 

Stain for 10 minutes or longer ; wash in water. Dry without 
using heat. 

The most common errors among beginners, in stained speci- 
mens, is the mistaking of a fragment of a leucocyte lodged 
upon a red cell for one of the ring forms of parasite. 

Blood Picture. — In the human blood there are only the nor- 
m.al elements with which to confuse malarial parasites; these 
are, erythrocytes, leucocytes, platelets, products of coagulation 
and technique. In the fresh specimen, shrunken, spiculated, 
crenated red cells and shadow corpuscles are often mistaken 
for parasites. Vacuoles in the red corpuscles, and fragments, 
often round in shape, adherent to the red cells, are frequently 
confused with the young hyaline or ring forms ; thread-like 
debris for flagella. Large pigmented leucocytes may be con- 
fused with the full-grown pigment bodies of the benign tertian. 

Heredity. — The question of heredity has been little considered. 
Duchek found a large pigmented spleen and pigment in the 
portal vein in a child dying three hours after birth, born of a 
malarious mother. Since the discovery of the Plasmodium, Bein, 
Bouzian and Peters found the malarial organism in the blood 
of new-born infants; probably, however, such infants had had 
opportunity to become infected since birth. By analogy there 
seems to be no good reason to controvert the idea of transmission 
of the malarial parasite through the placental circulation. 
Germs proper to diseases such as charbon, chicken cholera and 
septicemia, etc., have been demonstrated in the embryos of ani- 
mals dead of these respective diseases. The typhoid bacillus was 
found in the lungs, spleen, kidneys and mesenteric glands of 
a child five days old, the offspring of a mother who had con- 
tracted typhoid fever in the eighth month of pregnancy. Trans- 
mission of syphilis is assumed as obtaining through the pla- 



354 THE DISEASES OF CHILDREN. 

cental circulation. Big^nami, Bastianelli, Caccini, Thayer and 
Schaudinn have examined the blood of infants born of malarious 
mothers and placental blood, and the}^ do not believe the trans- 
mission through the placental blood. Though necropsies of 
several fetuses from infected mothers have negatived the pre- 
sumption of hereditary malaria, a positive conclusion is still not 
a violent one. 

Susceptibility. — The great liability of the child to get 
malaria becomes a question of easy solution when mosquito in- 
oculation is accepted. The child is the first to be put to bed 
and is the first to sleep ; the arms and legs and maybe half 
the body are bare. The skin is delicate and tender, and as com- 
pared with the adult, clean, the exhalations from this organ 
lack the odor emanating from the adult. The adult does not 
retire until the mosquitoes have filled themselves from the blood 
of their children; they are better protected by clothing, shoes, 
etc., and they are better able to avoid the bites of these insects 
than the infant or small child. 

After an entrance into the blood current, the susceptibility 
is still greater in the infant. The corpuscles upon which the 
Plasmodia feed offer less resistance; more of these bodies are 
destroyed, comparatively, at each paroxysm, than in the adult; 
consequently more toxins are liberated. 

Pathology. — The benign forms of malaria do not produce 
many fatalities, and it is the pernicious or malignant type that 
supply our necropsies. The characteristic chocolate and slate 
color of some of the tissues and organs of the body, produced 
by deposition of the peculiar malarial pigment, is found in the 
subacute and chronic cases. Accumulations of malarial pig- 
ment, dead parasites, debris and pavementing of infected red 
cells occur in the vessels of the hrain, stomach, liver, spleen, 
kidneys and other organs, producing actual thrombi and necro- 
biotic areas in some of these organs. When it is considered that 
one-sixth or even one-third of all the red corpuscles in the body 
may be destroyed by one single, pernicious paroxysm, it will 
be understood that the above-named organs may become pro- 
foundly affected. 

Liver. — The liver cells are thinned; the capillaries are dilated 



GENERAL DISEASES. 355 

and replaced by fat drops ; a great polyeholia is denoted by the 
filling of the gall bladder; injection of the bile capillaries to 
their finest rootlets. Xecrobiotic changes occupying rather ex- 
tensive areas are seen. The vessels are filled with pigmented 
leucocytes, dead parasites, remnants and debris, and blocks of 
yellowish-black pigment. Knpfer's cells and certain endo- 
thelial cells undergo multiplication by karyokinesis. This 
hepatic tumor has a blackish, leaden appearance, and is soft on 
section. More or less perilobular fibrosis obtains where there 
have been repeated infections. There is objection, however, to 
the idea of portal cirrhosis from malaria alone. 

Spleen. — The splenic tumor may be merely palpable below 
the costal margins, or it may reach below the navel and to the 
anterior superior spinous process of the ilium. Postmortem, 
the surface of the spleen is dark, sometimes black; on section 
the gland tissue is also found to be dark ; the parenchyma of the 
organ is much softened; the tarry pulp may be washed away 
with cjuite a gentle stream of water. The pigment of malaria 
is here found within the endothelium of the arterioles and capil- 
laries in minute grains, often in actual blocks; we find aggrega- 
tions of pigmented leucocytes, dead and breaking-down para- 
sites forming thrombi and actually occluding the vessels. The 
spleen and bone marrow have the distinction over all other 
organs of containing pigment in the cells of the parenchyma out- 
side and away from the blood vessels. In these latter organs 
pigment is contained in ordinary leucocytes, but in the splenic 
vein this subtance is included, not only in leucocytes, but also 
in certain large white cells identical with those occurring in 
the spleen, and evidently of splenic origin. 

Kidneys. — The renal changes are not as severe as has been 
supposed, especially in the milder forms of malaria. Grossly, 
they are slightly enlarged and pale in color. Small evidence of 
pigmentation. Microscopically, the glomeruli and the inter- 
lobular vessels are seen to contain infected red cells and pig- 
mented leucocytes. In the pernicious forms, and especially the 
hemoglobinurie form, the kidneys in the early stage of the 
disease are enlarged and congested; the tubules are blocked 
with hemoglobin infarcts; the cells are loaded with yellow pig- 



356 THE DISEASES OF CHILDREN. 

ment grains, and the capillaries with black malarial pigment. 
The appearances are then those of the large, white kidney. The 
severest cases of nephritis of malarial origin are found in 
hemoglobinuria. The capillaries in the medulla and papillae 
are often filled with infected cells and parasites; while the 
tubules are filled with casts, in which are, sometimes, entangled 
infected red cells, parasites and pigmented leucocytes. Ewing 
reports a case of acute hemorrhagic nephritis of malarial origin. 

The Bone Marroio. — Many sexual and pigmented forms and 
free pigment, pigmented leucocytes and macrophages harbor in 
the bone marrow. The small capillaries here are frequently 
choked. 

Respiratory Organs. — The bronchitic and bronchopneumonic 
manifestations are seldom seen in the very young. I have, 
however, seen several cases, in adults, where there was spitting 
of blood and other signs of pneumonia, accompanying the par- 
oxysm, and which cleared up with the administration of quinine 
and the subsidence of the fever. 

Symptoms and Clinical Outline. — It is the duty of the physi- 
cian to carefully instil into the minds of the parents the grave im- 
portance of noting the little indispositions, of whatever nature, 
of the infant in a malarial region. A child does not cry and 
fret, does not refuse to nurse or eat, does not get nauseated or 
become restless at night, will not stop play for nothing. The 
mothers in the bottoms soon learn this. Eternal vigilance here 
is the price of liberty. 

There is no disease which may reach alarming proportions in 
children so stealthily as that of malaria — yet so surely raises 
the danger signal, if one has been observant. 

We are to look for fretfulness, nausea, vomiting, stomachache, 
diarrhea, dysentery, epistaxis, excessive or scant urinary flow, 
drowsiness, fetid breath, coated tongue, headache, backache, 
feverishness and fever, etc. Any one or most of these symptoms 
may be present in a mild degree, one day, slightly more severe 
the next day — the third day (or even the second day) the blood 
is supersaturated with toxins, the nervous system is over- 
whelmed, pupillary manifestations appear — one pupil dilated, 
the other contracted, the extremities are in clonic convulsions, 



GENERAL DISEASES. 357 

the jaws are clinched, unconsciousness comes apace. This is the 
eclamptic form, or the condition generally known as ''con- 
gestion," from which so many babies die in the river bottoms 
of the South. Indeed, there is a general congestion, the most 
prominent symptoms may direct in one instance to the brain, 
in another to the liver, and still another to the stomach. The 
convulsions may be reflex in their nature, the point of irrita- 
tion which predetermines the flow of blood to a given organ 
or part being large accumulations of malarial pigment, dead 
parasites and debris, often occluding large vessels and lymph 
spaces. Often one sees families who have had born to them 
five, six and even ten children, and only one, two or three of 
these live to cheer and brighten their homes, and in each in- 
stance one is told that all of these little ones perished with so- 
called malarial congestion. 

However, not all children suffer wdth acute malaria; a good 
percentage of them have chronic malaria, cachexia ; one or two 
mild chills; quinine administered in mild doses just sufficient 
to prevent the next paroxysm, then given indifferently or not 
at all. The child goes on with considerable blood destruction, 
accumulating pigment, bile and malaria, their little skins take 
on a bronzed appearance, thickened and dry as parchment ; soon 
the spleen fills up and may be felt from 2 inches below the ribs 
to as low down as the iliac fossa, sometimes reaching across to 
the opposite side ; its pressure upward on the diaphragm, with 
the pain which is often centered in the upper part of the organ 
similates, and the parents are often apprehensive of pneumonia. 
The liver is more or less to be felt below the costal margins. 
Sometimes there are black, tarry stools. But more often these 
are clay colored. There may be constipation, the rule, how- 
ever, seems to tend towards a looseness of the bowels, the color 
of the stools in this latter condition is that well known of ' ' milk 
gravy." The urine is scant and scalding, highly colored and 
heavily loaded with solids; occasionally there is a flow of clear 
(water colored) urine. This may be regarded as a manifesta- 
tion of active malaria, and generally presages a paroxysm, how- 
ever mild it may be, followed by only a little back or leg pain, 
the Plasmodia may be sought in the peripheral blood. The 



358 



THE DISEASES OF CHILDREN. 



tongue is large and flabby, indented by the teeth, with a whitish 
cast; this, as are also the gums, is pale, anemic. 

Moncorvo believes that infants and children so infected are 
physically, mentally and morally deteriorated. He places 
malaria beside syphilis and tuberculosis, a retarder of physical 
growth. Every malariologist will attest that in the tropics and 
subtropics in the treatment of any disease, he has a malarial 



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base to work upon, even in wounds which confine to the bed or 
room malaria is precipitated. My experience fully accords with 
that of Moncorvo. It requires no stretch of the imagination to 
say what three or four generations of these little bronze fellows 
will bring. It becomes quite a social problem, when our most 
fertile lands are so poorly habitable on account of this infection. 
The fatality, according to L. Colin, of pernicious fevers, in 
an ascending scale is, icterus, comatose, delirious cardialgic, 
algid and syncopal. As previously stated, the benign forms of 
malaria do not produce many deaths, and are therefore easily 
amenable to treatment. 



GENERAL DISEASES. 359 

The liemoglohimiric form, upon which a great deal has been 
written, is, probably, only one of the very grave manifestations 
of pernicious malaria; the discussion of which could not be 
permitted by the space allotted here. 

What is the therapy of malaria? Every one knows how to 
treat chills and fever. Alas! it is that character of knowledge, 
sometimes, of which it is said : ' ' A little knowledge is a danger- 
ous thing." 

Prophylaxis. — The preventive steps and safeguards may be 
summed up in the following paragraphs : 

1st. Every effort should be made to banish from the blood 
all Plasmodia. Especially should the blood of infants be made 
malaria free, because anopheles prefer to attack infants on 
account of a delicate skin. This may be accomplished by the 
proper and timely administration of quinin. 

2d. All dwellings should be disinfected of mosquitoes, 
screened with close-wire netting, and extra precaution should 
be taken of placing close-gauze netting over each bed, and tuck- 
ing it in at the bottom. These bars should be inspected with a 
good light, before retiring at night, to guard against infected 
anopheles, having stolen in during the day or left in from the 
previous night. 

3d. All trees and bushes should be cleared away for a large 
area around each dwelling, weeds and grass should be mowed 
closely once a week. Puddles and pools should be filled up, or 
if too large covered with petroleum. 

Mosquitoes cannot live in the summer sun, nor propagate 
without water. 

4th. Patients with malarial parasites should be isolated and 
carefully covered w^th netting so that anopheles may not feed 
upon such patients and, becoming infected, inoculate other per- 
sons. Blood examinations should be made in all fever cases. 
The following is a report of a case of hemoglobinuria : 

This patient had a chill December 17. Quinin, in No. 2 capsules, was 
administered every four hours until hemoglobinuria came on. 

December 19. At 11.30 a. m. the patient was comparatively comfortable, 
and slightly drowsy. The urine was dark. A smear of blood was taken 
and while examining it I was hurriedly summoned. I found the urine the 



360 THE DISEASES OF CHILDREN. 

color of coffee. Both this and the first specimen responded to the guaiac- 
turpentin test. 

The first blood showed plasmodia. A second smear, taken after the urine 
colored up, showed plasmodia, estivoautumnal parasites in all stages of 
development, moderate poikilocytosis, a number of lymphocytes, leucocytes 
greatly increased, polymorphonuclear and mononuclear phagocytosis. 

The lips and gums were pale, also the tongue, which is large and flabby, 
with a thick, white coat, and a tinge of brown over the back part. Icterus 
notably mild. 

At 1.30 p. m. calomel, gr. x, and turpentin, gtt. xx — turpentin in a beaten 
egg — were administered, to be respectively, until the urine cleared up. 
Quinin dihydrochlorate, gr. viiss, hypodermatically, was given at 1.30, 5 
and 10 p. m., adding strychnin, gr. 1/120, to each injection. At 10 p. m. 
the urine was still black. 

December 20. At 8 a. m. the urine was clearing up nicely. Calomel 
was replaced by sodium hyposulphite solution, gr. xx, every two hours. 
Beef juice was ordered, a half teaspoonful every two hours. Quinin bi- 
sulphate in hot solution was ordered, gr. x, every four hours. 

At 5 p. m. the dihydrochlorate, gr. viiss, was given hypodermically to 
avoid paroxysm. A tepid bath, containing a little sodium bicarbonate for 
a cleanser, followed by hot whisky and quinin, was given. Sponge and 
normal salt enema every four hours. 

At 11.30 a. m. the urine was clear; turpentin was discontinued, and at 
5 p. m. the condition was practically normal. 

At 10 p. m. the urine was quite dark. 

The blood contained numerous hyalin bodies, crescents and round bodies; 
leucocytosis was marked. There were a few lymphocytes; phagocytosis was 
marked, and there was an abundance of pigment and pigmented leucocytes. 
Quinin dihydrochlorate, gr. xv, was given in solution. This was vomited 
and repeated immediately and retained. At midnight the fever was sub- 
siding rapidly, and the urine clearing up slightly. Turpentin, gtt. xv, was 
given at 10 p. m., and repeated in 2 drop doses every two hours until urine 
cleared. 

December 21. At 8 a. m. the urine was clear, and there was no fever. 
The blood contained free pigment, pigmented leucocytes and debris, also 
two old crescents. Quinin bisulph., gr. v, and strychnin nitrate, gr. 1/200, 
in solution was ordered. Sodium hyposulphite and beef juice to be given 
every two hours, and a bath and normal salt solution every four hours. 

December 22. At 8 a. m. patient was put on tonic and light diet. It 
will be noted that at 5 p. m., December 20, quinin, gr. viiss, was given hypo- 
dermically, yet the paroxysms came on at 10 p. m., at which time quinin, 
gr. XV, in solution by the mouth was administered and vomited, repeated at 
once and retained, and cinchonism was profound. This may be evidence 
of precipitation of the alkaloid by the alkaline tissues. 

Treatment. — When quinin for any reason is contraindicated 



GENERAL DISEASES. 361 

we are almost entirely ^^dthout a substitute ; this very fortu- 
nately does not often occur. Quinin and the other cinchona 
derivatives exert a specific action on the plasmodia, and all 
forms of malaria respond to its action, if the case is seen in 
time. An infant or child should not be allowed to have a second 
or third chill even of the benign types. Pernicious paroxysms 
of every variety, icteric, comatose, delirious, algid, eclamptic 
or syncopal require heroic treatment, and should he met 
promptly hy large doses of quinin hypodermically . 

The necessity for a good liver arousement is here very urgent. 
For the spasms, chloral hydrate or bromide of potash, either 
or both, may be used ; it Avill be found that these will be often 
vomited ; a hot mustard bath or a hot normal salt enema may 
be of value. 

For cachexia quinin in sufficient doses and tonics for 40 days 
in connection with tonics.^ 

SYPHILIS; LUES. 

Syphilis is a communicable disease, in infancy either heredi- 
tary or acquired. The latter form, evidenced by the initial 
lesion, the train of secondary lesions, showing in the mucous 
membranes and skin, and the tertiary manifestations in the 
bones, viscera and nervous system. 

Another phase which is of interest to pediatrists is that form 
of syphilis in infancy termed tarda, which Fournier states may 
' ' manifest itself at any age, from young adult up to old age. ' ' 

Etiology. — The recent investigations which have conclusively 
proven the spirocheta pallida to be the specific organism of 
syphilis have cleared up the etiology of this condition. This 
organism has been isolated and reproduced on the chimpanzee, 
and it has been found in the tissues of the syphilitic infant. 

The question of transmission of the syphilitic virus to the 
infant has been a moot one in medicine for vears. Belief in 



1 Bibliography. Thaver, Allbutt and Rolleson, Vol. TI, Part 2. Minchin, Allbutt 
and Rolleson, Vol. II, Part 2. Stephens, Allbiitt and Rolleson, Vol. II, Part 2. 
Ross, Brit. Med. -Tour. Stephens, Mannaberg, Nothnag^l, Vol. Malaria and Influ- 
enza. Deaderick for reprints. Burns, Hemoglobinuria ; Mosquito as a Definitive 
Host in Malaria. Mosquito as a Definitive Host in Malaria — A Further Considera- 
tion. Some General Remarks on M^larai; Malaria, Quinin in. Infantile Malaria: 
Laveran New Sydenham Society, Celli and Craig. 



362 THE DISEASES OF CHILDREN. 

parental infection direct, without infection of the mother, gave 
rise to Colles' law in 1837, which was as follows: 

A new-born child affected with inherited syphilis, even though it may- 
have symptoms in its mouth, never causes ulceration of the breast which 
it sucks, if it be the mother who suckles it, although continuing capable 
of infecting a strange nurse. 

In the light of modern knowledge of the etiology of syphilis, 
we know this law to be untenable. While the mother may seem 
healthy, she has become infected through the medium of the 
spermatozoa and ovum and is latently syphilitic, the syphilis 
being so mild in the mother as to escape observation. By 
means of reactions of Wassermann and Noguchi, which are 
typical only in the syphilitic, it has been shown conclusively 
that mothers bearing syphilitic children and showing no lesions 
are in fact syphilitic. 

Mode of Transmission. — The infection of syphilis may be 
carried to the embryo in the following ways : Direct from the 
father, through the medium of the spermatozoa, there causing 
an infection of the mother, which may or may not be recog- 
nized. The time of greatest infectious possibility in the father 
through the spermatozoa is after the primary and acute sec- 
ondary manifestations. The greatest danger of direct infection 
of the mother is during the early stages. It is, how^ever, claimed 
by some authorities that the disease is not transmitted by means 
of the spermatozoa. 

If the father becomes syphilitic after impregnation, infection 
of the fetus will be through the placenta from the mother direct. 

The infection may be from the mother direct, the father 
being healthy. 

If pregnane}^ is advanced some time in a mother not sj^philitic, 
and she contract syphilis later in pregnancy, the child may be 
born healthy. The chances of a healthy child being born is in 
direct relation to the duration of the pregnancy. If both parents 
are syphilitic before pregnancy, the offspring will be syphilitic. 

Treatment of parents after infection makes possible a healthy 
offspring after such treatment. 

A syphilitic woman who has not been intelligently treated, 



GENERAL DISEASES. 363 

will give a history of frequent early abortions or miscarriages 
before midpregnancy, or if progressed to full term will give 
birth to a syphilitic child. 

Pathology. — Syphilitic changes in the placenta are fairly typi- 
cal. The villi are much hypertrophied, and swollen vessels, some 
containing thrombi, are in the affected area. There is a fatty 
degeneration of the epithelial covering. In addition to this the 
spirochete pallida have been found in the syphilitic placenta 
though more often in the stroma and on the villi. The placenta 
is larger than normal. Nathan Larrier and Brideau ^ claim 
that spirochetes may be transmitted between maternal and fetal 
structures, and vice versa, as follows : 1st. A change in structure 
of the villus and the passage of the parasite through the media- 
tion of perivascular infarcts with or without the intervention 
of leucocytes, a pathologic process. 2d. Transmission of the 
treponema by the proliferating cells of Langhans a physiologic 
process, an important factor because of the ability of the cells 
of Langhans to penetrate into the vascular system of the 
decidua. 

The spirocheta may be found in many of the organs of the 
infant, the liver, lungs, ovaries, testes, spleen, and in the blood. 

The principal changes which take place in the fetus as the 
result of syphilis occur in the bones, certain of the viscera, the 
skin and the lymph nodes. In the hones there is an inflamma- 
tion at the site of greatest activity and growth, or a deposit 
of bony tissue on the shaft of the bone. AYhen this inflam- 
matory deposit occurs in the proximal ends of the phalanges it 
is termed a dactylitis. The long bones are chiefly affected. 

The liver shows an interstitial change and usually is en- 
larged. There is a round-cell inflammation in this organ. 
Gumma may be found. The spleen is enlarged and also shows 
the same increased connective tissue as the liver. The same 
hyperplasia of connective tissue is found in the lungs and 
kidneys. The lymph nodes show a round-cell infiltration and 
enlargement. 

The lesions in the shin may be of many kinds, erythema, blebs, 
bullge, papules, and pustules. The mucous meynhranes may show 



Wall: American Journal of Obstetrics, June, 1908, 



364 THE DISEASES OF CHILDREN. 

superficial or deep ulceration. These may be the typical mucous 
patches. 

Symptoms. — A syphilitic child may be prematurely born, 
macerated and covered with characteristic skin lesions, may be 
born apparently healthy, with development of symptoms shortly 
after birth, or present no symptoms for weeks or months after 
birth, these cases being classed under syphilis tarda. 

In the second class of cases the symptoms usually develop 
during the first six weeks, and may be classed under those af- 
fecting the skin, mucous membranes and bones. 

The skin will usually show a maculopapular syphilide upon 
■the face, neck, hands and feet, and especially about the buttocks. 
The first skin disturbance may be found about the anus. This 
eruption may be discrete or confluent. When severe, occasional 
bull^ or blebs may appear, and if they become infected, pustules 
appear, which form large crusts or scabs when they coalesce. 
Condylomata appear about the anus. Blebs and bullae may be 
found in relatively large numbers on the palms of the hands 
and soles of the feet. 

Coincident with the skin lesion, sometimes antedating it, a 
coryza develops, the snuffles, which is quite characteristic of 
the condition. The snuffles is often preceded by an inflamma- 
tory condition of the posterior nares with profuse secretion, 
which is swallowed. The snuffles may be present at birth. There 
is a tendency for the mucous membrane at the corners of the 
mouth and at the anal margin to crack. When at the anus es- 
pecially they are termed rhagades. Mucous patches appear upon 
the buccal mucous membrane at this time also. 

An enlargement of the epiphyses quite regularly occurs of 
the long bones and the phalanges. These swellings may be pain- 
ful and tender. Dactylitis usually forms, and this may involve 
the metacarpal and metatarsal bones also. Only one bone may 
be involved. The parietal and frontal bosses are enlarged, and 
immediately behind the parietal eminences a thinned and 
softened bit of bone is found, the typical craniotahes. In a 
lesser number of cases craniotabes may be found in the oc- 
cipital bone also. Softening and degeneration of the bones of 



GEXZRAL DISEASES. 365 

the nose may occur. The spleen is quite regularly enlarged 
and easily palpable. It is usually much larger than in othei? 
morbid conditions. The lymph nodes are very generally en- 
larged. Most freciuently the epitrochlea, cervical, axillary and 
inguinal glands are affected. 

The child ciuickly develops into an anemic, run-down condi- 
tion. Because of the snuffles its nursing is interfered with and 
its nutrition is quickly impaired. It is anemic and a condi- 
tion of athrepsia soon intervenes. 

In sifphilis hereditaria tarda, in which the symptoms may 
develop at any time from three months to puberty, the triad of 
symptoms as given by Hutchinson are interstitial keratitis, 
labyrinthine deafness and deformity of the upper incisor teeth. 
Corneal opacity is a result of the keratitis. The teeth may be 
peg shaped or notched, with transverse ridges across them. 

Gum mat a may develop at any place in the body, and not in- 
freciuently they appear upon the skin. "When in the brain or 
cord, symptoms referable to these regions deA'elop. Synovitis 
is not infrec[uent. 

Diagnosis. — This should not be difficult in cases born pre- 
maturely, presenting the skin lesions and bony changes. Eic'kets 
may present some symptoms which are suggestive of syphilis, 
but the diagnosis should not be difficult. Rickets develops, as 
a rule, later, and the skin symptoms are not present. The bony 
changes in rickets are usually symmetrical, single joints being 
affected in syphilis. Later Hutchinson's teeth are confirmatory 
evidences of syphilis. 

Prognosis. — The influence of syphilis upon infant mortality 
is not generally appreciated. Statistics ^ show a fetal mortality 
in paternal heredity under most favorable circumstances, of 28 
per cent : in maternal heredity, of 67 per cent, SQ per cent 
and 71 per cent, according to diff'erent observers, and in mixed 
heredity from QS per cent to S^ per cent. ]\Iorrow states that 
one-third of all children born syphilitic die before they reach 
the age of six months. Syphilis then becomes one of the most 
severe of the scourges affecting the infant population. If a 



^Author's paper: Syphilis Affecting Infant llortaliti/. Journal A. M. A., 190-4. 



366 THE DISEASES OF CHILDREN. 

syphilitic infant is breast fed it has a better chance to recover. 

Treatment. — If a diagnosis is made of syphilis in either parent, 
every means should be used to prevent conception. 

If pregnancy occurs, by a syphilitic father, in a mother who 
shows no signs of syphilis, if she is put at once upon an anti- 
syphilitic treatment, which is conscientiously carried out during 
gestation, she may give birth to a healthy child. If she gives a 
history of frequent interruptions of pregnancy before term, from 
syphilitic causes, she may go to full term and give birth to a 
healthy child, provided active treatment is undergone during 
the entire pregnancy. The mother should nurse the child and 
continue treatment. A wet nurse should not nurse a syphilitic 
child. 

The treatment of a child, the subject of congenital syphilis, 
should be begun early and be faithfully carried out. It should 
be continued until the symptoms are decidedly improved and 
then discontinued for a week, then resumed for a period of 
three or four weeks. Gradually increase the interval between 
a course of treatments. The child should be kept under treat- 
ment for at least two years, better for three years. Mercury 
should be used in the early stages and can be given by 1, the 
moutli; 2, hy the skin, and 3, suhcutmieously. 

In all forms of administration symptoms of saturation should 
be looked for. 

1. By the mouth, the following preparations can be used : 
a. Hydrargyrum cum creta (gray powder), in 1 grain doses, 
three times a day. The chalk usually controls the laxative effect 
of the mercury, but if it does not Dover's powder, 14 grain, can 
be combined for its effect. The dose of gray powder can be 
increased later, h. Calomel, in doses of 1/30 to 1/10 of a 
grain, three times a day. Dover's powder, 14 grain, may also 
be used with this if it causes diarrhea, c. Bichloride of mer- 
cury, with sugar of milk, in 1/60 to 1/40 grain doses, d. Pro- 
toiodide of mercury, in dose of 1/15 to 1/10 grain. 

2. By inunction the following can be used: a. Ung. hydrar- 
gyri with equal parts of lanolin, a piece the size of the end 
of the little finger being rubbed twice daily, or about 5 grains 
of the mercury into the flexures of the body, alternately, h. 



GENERAL DISEASES. 367 

Oleate of mercury, from 1 to 5 per cent, may be used in the 
same way, or as suggested by Kotch, saturating the binder with 
it and allowing it to be Avorn for 48 hours. Except in hospitals, 
this method of treatment is very unsatisfactory, and frequently 
severe dermatitis is caused by the inunctions. 

3. By injection, can be given bichloride of mercury in a 
2 per cent solution, 4 to 8 minims, every two or three days. 
This method of treatment is very impractical in children. A 
general supervision should be had over the feeding, habits and 
sleep of the patient. Breast milk is the best food, but not from 
a wet nurse. These children resist infections and illnesses very 
poorly, hence should receive the best nourishment and be pro- 
tected from contagions. 

The treatment of syphilis in children by Salvarsan (Ehrlich's 
606) has received much attention. A word of caution cannot 
go amiss as to the use of this preparation in children. It has 
not been used frequently enough for the last word to have been 
said in regard to it. 0.008 to 0.01 grams per kilogram of body 
w^eight has been given as the guide for infantile dosage. It 
may be given intramuscularly or intravenously. 

Treatment of the Special Symptoms. — The catarrhal condition 
of the nose causing the snuffles requires cleansing washes. Do- 
bell's or Seller's solution in spray or douche, followed by cal- 
omel insufflation or ointment (1 part to 20), or the ung. hydrar- 
gyri ammoniati, applied to the cavities. For fissures about the 
mouth and rhagades at the anus, dry calomel is of benefit. Diar- 
rhea may need treatment by discontinuance of the mercury and 
administration of bismuth alone, or combined with Dover's pow- 
der. 

Potassium iodide is given only when tertiary symptoms de- 
velop, hence late in the affection, and this drug pushed to point 
of saturation. 



CHAPTER XVI. 

CONTAGIOUS DISEASES. 

ACUTE EXANTHEMATA. 
MEASLES. 

Synonyms. — Rubeola, morhilli, flechern, masern. 

Definition. — Acute, eruptive, febrile disease caused by a spe- 
cific contagion. It is characterized by a period of incubation, 
a prodromal stage, with catarrhal symptoms and fever, a stage 
of eruption upon the skin and mucous membrane of the respira- 
tory tract, and a stage of desquamation. 

Etiology. — Measles is perhaps the most contagious of the erup- 
tive diseases, though the specific organism which is the cause of 
it has never been isolated. The organism is shorter lived, evi- 
dently, than the organism which causes the other contagious dis- 
eases. Occasionally a natural immunity is seen. One attack 
usually confers immunity although recurrences are not unusual. 
Children under six months of age are less susceptible than 
older ones, and adults who have not had the disease in childhood 
may contract it. The contagious period exists throughout the 
whole course of the disease, though the early acute catarrhal 
stage is supposed to be the most contagious. 

The contagium in cities rarely entirely dies out. It is very 
often endemic and frequently epidemic in character. Because 
of the closer housing of children in winter, and the schools being 
in session during these months, it is more prevalent in winter 
than in summer. Apparently it is possible for sporadic cases to 
develop w'ithout being able to trace the infection. It has been 
stated that the contagium cannot be carried through the medium 
of the second person or by means of toys, clothing, etc. No milk 
borne epidemics have been recorded. 

The practice which is frequently seen in cities of mothers de- 
liberately exposing their children to the contagium of any of 

368 



CONTAGIOUS DISEASES. 369 

the exanthemata is one which cannot be too violently denounced. 

It occurs more frec[uently during the first six years of age. 

Mason ^ has reported a case of measles in utero. The mother 
was delivered after a typical attack, 'during the stage of des- 
quamation, and the child showed a mottling of the skin and 
profuse general desquamation which persisted for 20 days. 

Pathology. — The chief changes are in the mucous membranes 
and skin. The enanthem, Koplik's spots, are usually present 
from twenty-four to forty-eight hours before the exanthem. 
They are bright red spots of infiltration in the mucous membrane 
of the cheeks and lips. A round-cell infiltration occurs in the 
skin, especially around the hair follicles and sweat glands. 
There is an engorgement of the skin capillaries during the erup- 
tive stage. The conjunctivc-e are engorged and the natural se- 
cretion greatly increased. 

Symptoms.^The symptoms are generally divided into three 
periods, that of incu'bation, prodrome or invasion, eruption and 
desquamation. 

InciCbation — The duration of the period of incubation is from 
8 to 14 days, the eruption usually appearing between the tenth 
and fourteenth days after exposure. Usually there are no symp- 
toms referable to this period, until 48 to 52 hours before the 
appearance of the eruption. 

The Prodromal Stage or Period of Invasion. — Two or three 
days. The first symptoms of this stage are usually those caused 
by the catarrh of the respiratory and conjunctival mucous mem- 
branes. These may be preceded by vomiting, slight headache, 
lassitude, and within a very short time ^^ill be seen a coryza and 
reddening of the eyes, photophobia is pronounced, a harsh 
throaty cough, perhaps some hoarseness, if the larynx is involved, 
with more or less bronchitis developing later. 

Beginning with the advent of the catarrhal symptoms, there 
is a rise of temperature, varying from 101° to 104° F., reaching 
its height with the full appearance of the eruption. There is a 
slight morning remission of perhaps 1° F., and the rise in the 
afternoon. There is an increased drowsiness and almost entire 
loss of appetite. 



* Boston Medical and Surgical Journal, October, 1908. 



370 



THE DISEASES OF CHILDREN. 



Koplik has described a condition which is present upon the 
mucous membrane of the mouth, from 24 to 48 hours, before the 
appearance of the eruption upon the skin. This, as described 
by Koplik, is a bright red spot on the mucous membrane of the 
cheek and lips, in the center of which is a minute bluish-white 



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Fig. 70. — Measles. 

speck. This enanthem can only be seen in a good light, and 
the spots are very characteristic when found, and Koplik claims 
that they are pathognomonic of measles. 

Eruption. — This usually appears on the third or fourth day. 
It is a dusky red, pin-head eruption, usually appearing first 
upon the sides of the neck and about the margin of the hair, 
then upon the chest and face, and gradually the whole body is 
covered. The eruption is much less prominent upon the lower 
extremities than upon the body and arms. It sometimes be- 
comes confluent. It varies in color and is decidedly more dusky 
red than the eruption of scarlet fever. The rash may appear 
crescentic in form but the spots are usually irregular in out- 
line. 

In the very severe forms measles is sometimes designated as 



CONTAGIOUS DISEASES. 371 

black measles, the eruption is of a bluish-black color which is 
due to the extravasation of blood under the skin. This form 
is also called malignant measles. 

The duration of the eruption upon the skin varies from three 
to five days. With its disappearance there is left a slight dis- 
coloration or mottling of the skin, which may remain for several 
days. 

The eruption fades first from the mucous membranes and 
from the skin in the order in which it first made its .appearance', 
and if the congestion of the skin has been very intense the des- 
quamation begins in small bran-like scales in the same order. 
This scaling has also been described as furfuraceous. The des- 
quamation is not at all regular, as frequently cases are seen in 
which no desquamation takes place at all. It is usually pro- 
portionate to the amount of temperature and severity of the 
rash, and continues from four days to a week. 

As the rash disappears, all of the symptoms gradually im- 
prove, the fever shows a regular decline, the cough improves, 
there is a slight return of appetite, photophobia disappears, 
though the eyes may remain weak for some time, and a mild 
conjunctivitis may also remain. 

Atypical Oases. — In an epidemic many varieties of cases are 
encountered. They may be so mild as to go practically unrec- 
ognized, in which the rash is very slight, there is very little fever 
and few catarrhal symptoms. Frequently, unless these cases 
occur in an epidemic, they go unrecognized. 

Malignant. — This form is decidedly the most fatal and occurs 
in children with very little resistance. The eruption is very 
severe, frequently of the hemorrhagic type, ordinarily called 
black measles. Sometimes the malignant form may have but 
little rash, and the severe symptoms are caused by the severity 
of the complications. In this form of cases, pneumonia is the 
principal complication and the cause of the majoritj^ of the 
fatalities. In this the rash not infrequently disappears more or 
less rapidly. The laity look upon this condition as "striking 
in'\of the rash, considering it the cause of the complication. 
This phenomenon is a result of the complication and not the 
cause. 



372 



THE DISEASES OF CHILDREN. 



Complications and Sequelae. — The chief complications are those 
of the respiratory tract ; bronchitis and bronchopneumonia. The 
j'Ounger the child, the more liable it is to develop pneumonia, 
and it is the most frequent cause of death. This complication 



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Fig. 71. — Measles with complicating pneumonia. 

is due to invasion of the respiratory mucous membranes by the 
pneumococcus and the streptococcus, and in practically every 
fatal case of measles, more or less hroncJwpneumonia will be 
found. 

Catarrhal laryngitis and pliaryngitis are very often present, 
and in these cases in which this is a feature an invasion of the 
middle ear is more often present. Spasmodic croup has been 
reported as a complication. Otitis media is a frequent compli- 
cation. It has not been my experience to see many cases of 
pseudomembrane upon the tonsils or pharynx in measles, though 
it has been frequently recorded by various authors. A cellulitis 
of the skin of the external auditory canal may occur. Conjunc- 
tivitis is a very frequent complication. There is always a con- 
gestion of the conjunctiva and this may persist especially in 



CONTAGIOUS DISEASES. 373 

poorly-nourisliecl children for some time after the disappearance 
of the rash. 

Tuberculosis. — Because of the catarrhal condition and adenitis 
resulting from measles, the soil is ripe for the absorption of 
the tubercle bacilli and their development. The frequent occur- 
rence of bronchopneumonia also offers a site for their develop- 
ment and propagation. The tubercular process may have been 
latent and an attack of measles all that was needed for its light- 
ing up. 

Cutaneous Complications. — A general pruritic condition of the 
skin may be present in measles, especially during the early 
eruptive stage. This may be partly due to a sudaynina, or 
blocking of the sweat glands, and consecjuent formation of 
minute vesicles and great itching. Herpes labialis and facialis 
is frequently seen, and iirticdna is also a complication. This 
may take the form of the large wheals or the minute papules 
which itch greatly. In the grave or hemorrhagic form noma 
may develop, due to an infective embolus finding lodgment in 
the cheek or perhaps an extension from an ulcerative stomatitis. 

Prognosis. — This depends to a great extent on the individual 
child, on the character of the epidemic or endemic, the age of 
the child and the complications. The mortality from measles 
itself is not very high. The occurrence of pneumonia or any 
bronchial irritation renders the prognosis much less favorable. 
This one complication is the cause of the largest percentage of 
deaths in measles. 

The early evidence of toxemia makes the prognosis less 
favorable. 

The uncomplicated form of measles in a child over four is 
usually not very severe. 

Prognosis is bad in cases with such complications as laryn- 
gitis, otitis, diphtheria, hemorrhages in the skin. 

Diagnosis. — With the first description of the buccal eruption 
in measles by Koplik, the diagnosis became much more easily 
made, for in connection with the catarrhal symptoms present 
the diagnosis can be made even before the rash has appeared. 

Ruhella is apt to be confounded with measles, as the rash is 
very similar indeed. In this condition, however, all the syrap- 



374 THE DISEASES OF CHILDREN. 

toms are less severe, little or no fever, very slight catarrhal 
symptoms, the rash appears more quickly and remains out a 
shorter time, and desquamation is rarely seen. The post cervical 
adenitis, is a characteristic sign in rubella and not a constant 
one in measles. 

Scarlet fever is less apt to be confused as the rash is so en- 
tirely different. There are but few if any catarrhal symptoms 
or cough in the early stages. The scarlatinal throat and tongue 
are not present in measles. 

Drug eruptions and the eruption due to an intestinal toxemia, 
the so-called "stomach rash," may cause some confusion in 
diagnosis. Rashes occur from the administration of antipyrin, 
quinin and chloral and the* antitoxin sera. In all of these the 
catarrhal symptoms are absent, usually but little fever, and 
not suggestive of measles in its range. 

Treatment. Prophylaxis. — As already stated, there is a wide- 
spread belief indulged in that all children should have the con- 
tagious diseases, unfortunately, by some physicians, and too 
many cities having the contagious disease placard system omit 
measles from the list of diseases to be reported and placarded. 

This lack of concern results in lax efforts at isolation and 
many unnecessary cases and deaths occur. 

Strict quarantine should be maintained and the child isolated 
as soon as a history of definite exposure has become known. 
Then when it is ready to be relieved of quarantine, when des- 
quamation has ceased, and no catarrhal symptoms persist, the 
final cleansing bath and room preparation should be insisted 
upon. Quarantine should be maintained at least three weeks. 

Uncomplicated measles is a more or less self-limited disease. 
The curative measures will therefore be largely directed toward 
the prevention of complications. Hence, to prevent pulmonary 
involvement, the child must be kept in bed in a large, airy room, 
with plenty of fresh air. The light must not shine direct in 
the eyes, but there is no necessity of keeping the room entirely 
dark. The head of the bed should be turned toward the light 
and covered with a sheet to keep out the bright light. 

The eyes should be bathed at least twice a day with a warm 
ten per cent solution of boracic acid. The nose should be 



CONTAGIOUS DISEASES. 375 

sprayed or irrigated with the same solution or with a normal 
salt solution. 

Fresh air should be insisted upon. The child should be pro- 
tected with sufficient clothing and outside fresh air let in. 

The harsh, dry cough which is apt to keep the child awake 
should be controlled. Moist air, obtained by keeping a steam 
spray going in the room near the bed by a croup kettle or steam 
atomizer is of great assistance to this end. ' To the water can 
be added tinct. benzoin comp. (5i to Oi) or oil of eucalyptus 
(5ss to Oi), both of which, in connection with the moist air, 
have a sedative action on the mucous membrane of the throat 
and larynx. Codeine in % to i/4 gr. doses, plain or with a tea- 
spoonful of brown mixture, can be used with great benefit for 
the cough. Wet, cold compresses to the throat, protected by 
a dry flannel, wider than the wet one, and changed every four 
to six hours, will be found of service also. 

If, during the early eruptive stage, there is great restlessness.^ 
3 to 5 grain doses of potassium or strontium bromide can be 
given at three-hour intervals, or small doses of phenacetine. 

Unless there is hyperpyrexia the fever needs no attention. If 
it remains persistently above 103° F. it is best controlled by full- 
tub baths, wet pack or sponge baths. It is not advisable to give 
coal-tar products in any form. Enemas, when needed for acute 
constipation, should be given cool (70° to 80° F.) in the presence 
of high temperature. 

In those cases in which the eruption is slow in appearing a 
warm bath (100° F.) will be found of service. It quiets rest- 
lessness and favors the appearance of the rash. 

In measles, as in the other exanthemata, keeping the child 
wrapped up too warmly in a hot, unventilated room, and the 
withholding of cool drinks and giving hot or warm solutions in 
order to ^^ bring out the rash" should not be tolerated. 

"While nephritis is an unusual complication in measles, it can 
occur upon exposure, and during convalescence the child should 
be protected from undue exposure to cold draughts. 

Bronchopneumonia is evidenced by a sharp rise in the tem- 
perature and an increase in pulse and respiration ratio and 
evidence of prostration. The treatment of this complication 



376 THE DISEASES OF CHILDREN. 

does not differ from a bronchopneumonia occurring primarily. 

Iron and cod liver oil are indicated in the convalescence, 
especially when a bronchial irritation and anemia persist. 

During the stage of desquamation the child should have a 
daily bath, in a tub if possible, and after drying should receive 
a general anointing with an unguent, a 1 per cent carbolic acid 
in vaseline. This is useful to allay itching and as an antiseptic 
also. 

GERMAN MEASLES. 

Synonyms. — Rotheln, UiiheMa. 

This is an acute specific, infectious, eruptive disease usually of 
mild nature, and of shorter duration than the other exanthemata, 
and not at all related to them. It does not protect the individ- 
ual from any of the other exanthemata. It is characterized by 
a period of incubation, a prodromal stage, followed by an erup- 
tion. 

Etiology. — The bacteriology of this disease is not known. It 
may be sporadic but is usually epidemic, and may occur at any 
age. It is more frequent in children from two to five years of 
age. I have seen an epidemic of rubella and rubeola in an in- 
stitution at the same time. A child would have an attack of 
one form, and in a few days return with a typical attack of the 
other. In some cases German measles preceded ; in others 
measles. 

Symptoms. — The period of incubation is more variable than 
in the other exanthemata. The average is about 15 days, vary- 
ing from 5 to 18 days. There are, as a rule, no symptoms 
during this stage. 

During the stage of invasion, which may last from a few 
hours to two or three days, the child may be restless and peevish, 
complain of headache and sore throat, evidence some catarrhal 
symptoms, lacrimation and cough, but these latter are by no 
means constant. As a rule there is from 1° F. to 2° F. rise in 
temperature during this stage, the fever being higher as soon as 
the rash appears, gradually subsiding when the rash is pro- 
nounced. Stage of eruption begins with the appearance of the 
rash on the face and neck, soon spreading to the trunk and arms, 
and finally very sparsely, as a rule, upon the legs, the rash 



CONTAGIOUS DISEASES. 



37' 



reaching its height within 36 hours. By the time the rash ap- 
pears upon the legs it has begun to fade on the face and neck. 
It is not unusual for the rash to have entirely disappeared 
within 48 hours from its onset. 

The rash appears as a faint red macule, slightly larger than 



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Fig. 72. — German measles. 

a pin head, and becomes a rose-red in color. There are areas 
of normal skin between the macular spots, unless the eruption 
becomes confluent, which is unusual. 

This is the variety of rubella which is usually referred to as 
the measles variety. 

The other variety is described as the scarlatinaform variety, 
the exanthem resembling that seen in scarlet fever. The differ- 
ence between the two forms of rubella are simply in the character 
of the rash. In the scarlatinaform variety the rash is much 
more widely distributed, does not occur in such large macular 
spots, and the skin has a more uniform redness. 

The mucous membrane of the mouth and throat is reddened 
but there are no Koplik's spots. 



378 THE DISEASES OF CHILDREN. 

In rubella there is almost constantly found an adenitis, the 
lymph nodes most frequently found enlarged being those of the 
neck, both back and front. This symptom occurs in fully 
90 per cent of cases, and is a valuable diagnostic sign, as an 
adenitis is not nearly so frequent in the other varieties of ex- 
anthemata. The swelling of these glands quickly subsides after 
the fever and rash disappear. 

Desquamation in rubella is not as regularly seen as in measles 
and scarlatina. Like in measles, the amount of the desquama- 
tion is proportionate to the severity of the eruption, and is 
bran-like and scaly, and is not prolonged, rarely lasting more 
than a week. The desquamation laaj be simply a roughening 
of the skin and not at all decided. 

Complications and Sequelae. — These are very infrequent and 
rarely severe. A gland or group of glands may break down and 
require lancing- to evacuate the pus. Stomatitis is sometimes 
seen, but is never of the gangrenous type ; pneumonia is much 
less frequent than in measles; otitis media may occur. 

Diagnosis. — This is frequently very difficult indeed. It must 
be made from measles, scarlet fever and vaccinia. When it is 
remembered that rubella is most apt to occur in epidemics, all 
its symptoms are less severe, rash not so profuse and more dis- 
crete ; less fever ; adenitis present in almost every case and has 
few complications or sequelaa, the diagnosis is usually easy. 

Prognosis. — This is almost universally good, especially so 
where the hygienic conditions are all right. 

Treatment. — But little treatment is required, confinement to 
bed during the eruptive stage, and while the fever lasts, in a 
properly ventilated and heated room; cleansing sprays and 
washes for nose and throat, attention to bowels; bathing, both 
for cleansing and antipyretic purposes, and anointing during 
the stage of desquamation. 

SCARLATINA. 

Synonym. — Scarlet fever, scharlacli. 

Definition. — An acute, specific, highly contagious and infec- 
tious, eruptive, febrile disease. 

Etiology. — The specific organism, the cause of scarlet fever, 



CONTAGIOUS DISEASES. 379 

has not yet been isolated, but it is unquestionably due to an 
organism, and associated Avitli it is the streptococcus in a large 
percentage of cases.' It is the streptococcus which is the cause 
of so many of the complications of scarlet fever, and it is prob- 
ably the mixed infection which is present that accounts for the 
severity of so many cases. 

The contagium lives for a long period of time, and can be 
carried great distances by articles handled by the sick child. 
A number of epidemics of scarlet fever have been traced to 
milk as the carrier of the infection, and in every epidemic the 
milk supply should be closely investigated. 

Scarlet fever is most frec[uent between one and five years of 
age, though cases are on record in children much younger. It 
is rare before the sixth month. 

A natural immunity may exist. Second attacks are not un- 
common. Adults are less susceptible than children. 

The discharges from the nose, mouth, throat and bronchi are 
most virulent as carriers of the contagium, the desquamated 
skin being also a disseminator of it. Hence, scarlatina is con- 
tagious throughout all its course. The port of entry of the con- 
tagium is most likely the nasopharynx. 

As in measles, because of the close housing and crowded school 
rooms, during winter, more cases occur in this season than dur- 
ing the summer months. I have never seen a case of scarlatina 
in a negro, and I believe it is very uncommon in this race. 

In spite of the long life of the contagium, scarlatina is not 
nearly so prevalent "as measles. I have frecjuently seen one case 
of scarlatina removed from a dormitory of children without 
the second case developing, while in epidemics of measles prac- 
tically all the children would be attacked. 

The mucous discharges from the nose and mouth and the des- 
quamated skin are the chief sources of contagion. Hence, any- 
thing handled by the patient, especially during the stage of des- 
quamation should be carefully disinfected or destroyed. The 
bedding from the child 's bed, the clothes and night dress should 
be most carefully disinfected. 

Symptoms. Period of Incuhaiion. — This is usually shorter 
than the other eruptive diseases, lasting from a few hours to 



380 THE DISEASES OF CHILDREN. 

6 to 10 days. The onset of the stage of invasion is short and 
sudden, it appearing to attack a child apparently well. It is 
attended by sore throat, vomiting;, rigors, fever, rapid pulse, 
headache, and loss of appetite. Infrequently convulsions may 
usher in an attack in younger children. 

The tongue is covered quite heavily with a grayish-white coat, 
with a cleaning off of the edges at the beginning of the stage of 
eruption. About this time also the red papilla begin to show 
through this coat, which at the tip becomes quite thin, giving to 
the tongue the appearance of a strawberry. This is considered 
a confirmatory sign of scarlet fever. About the fourth day of 
the rash the tongue is clean and papillae quite prominent. At 
this time the tonsils are swollen and red; perhaps a slight exu- 
date may have appeared on one or both. 

Stage of Eruption. — The eruption appears usually within 24 
hours after the first symptom, which as a rule is the vomiting, 
is noted. It comes out on the neck first, and about the same 
time spreads to the chest and faintly on the face, and shortly 
afterward the entire body is covered. It is more distinct on the 
flexor surfaces of the extremities than the extensors. The flexor 
surfaces of the joints may not present the typical rash. 

The scarlatinal rash is a minute punctate elevation on the 
skin, with areas of normal skin between, but the skin has the 
appearance of having a uniformly dull red hue when viewed 
at some distance. This is due to the erythematous background. 
The skin is blanched on pressure, the dull red color promptly 
appearing on removal of this. There may be large areas of nor- 
mal skin, and the rash looks patchy. It is impossible to make a 
diagnosis of this rash except in a good light. Frequently minute 
vesicles may be seen. Itching is often present. 

The rash disappears first from the parts of the body where 
it first appeared, leaving the skin rough, and this is followed 
by a general desquamation. The eruption lasts from three to 
seven day's, but undoubtedly cases are encountered in which 
the rash is so slight as to go entirely unnoticed. 

I have had such a case under observation. The prominent 
symptom was the gangrenous tonsillitis, and the boy was treated 
for this entirely. About 10 days later, after being dismissed 



CONTAGIOUS DISEASES. 381 

with all symptoms in the throat absent, he consulted me again 
to ask why his hands were peeling, and exhibited a hand which 
had the typical scarlatinal desquamation, the skin coming off 
in large scales. 

Desquamation. — This begins upon the parts where the rash 
first appeared. On the body the peeling is furfuraceous, the 
skin coming off in larger scales than in measles. These scales 
are perforated and they have been referred to as ''pin-holing." 

Desquamation begins with the subsidence of the fever. The 
typical scarlatinal desquamation begins upon the hands and feet 
soon afterward. Cases have been reported where entire casts of 
the hands and feet were thrown off. It begins at the free border 
of the nails. This form is referred to as a lamellosa. The 
finger nails show characteristic signs in this stage. If the skin at 
the matrix margin of the nail is pushed back a cracked line is 
noted extending up to the matrix. This is best seen on the 
thumb. No desquamation whatever may follow an unquestioned 
case. The appearance of the finger nails during desquamation 
has been described as characteristic. In the sub-ungual spaces 
with the finger tips pushed back, is seen a cracked line extending 
to the fingers. 

The duration of desquamation is from two to ten weeks, the 
average being about five weeks. 

Fever.^-Theve is no typical temperature curve in this disease, 
but it is high in proportion to the streptococcic involvement and 
reaches its height by the second or third day. If everything is 
progressing favorably the temperature begins to fall with the 
recession of the rash, and it rises with the development of any 
complications. " 

The pulse is almost always rapid, out of proportion to the 
temperature and respiration ratio. There is a genei^al enlarge- 
ment of the superficial lymph nodes, not limited as the enlarge- 
ment is in German measles to the cervical region, but appearing 
in the groin, and axilla also. 

The throat is congested from the rash on the mucous mem- 
branes quite early, and an exudate is very often seen after the 
second or third day, principally upon the tonsils, but it may ex- 
tend to the uvula and posterior pharyngeal wall. These exudates 



382 THE DISEASES OP CHILDREN. 

may be due to the streptococci or to the diphtheria bacillus, and 
a culture is generally necessary to decide to which organisms it 
is due, these cases being known as the original form. 

The urine should be regularly examined during scarlatina. 
During the height of the eruption the quantity is reduced, but 
at the end of the first week it returns to normal. It is not un- 
common for albumin to be present throughout the disease in 
small quantities and sometimes the renal derivatives, epithelium, 
blood, granular and hyaline casts, but they are found more fre- 
quently during the stage of desquamation. An acute Bright 's- 
disease is not regularly seen, but it does occur as a complication 
very frequently. 

The blood shows a diminished number of red blood cells and 
a leucocj^tosis is present both before the rash appears and 
throughout the entire course of the disease. In the anginal 
form this sign is more marked. There is an increase in the poly- 
nuclears and the eosinophiles are absent. 

Complications. Otitis. — A purulent inflammation of the mid- 
dle ear is one of the commonest complications. It may occur 
in cases in which there is no tonsillar exudate, and a spontaneous 
rupture of the drum is nearly always the result. Scarlatinal 
otitis is one of the most frequent causes of deafness, and is a 
complication to be dreaded. Its presence is usually indicated 
by deafness, earache and rise in temperature, followed soon 
after by a spontaneous rupture of the drum. The presence of 
the pus in the auditory canal or the staining of the pillow no- 
ticed when the child awakens may be the first evidence of this 
trouble. Frequent examinations of the ear drums are import- 
ant, and a paracentesis done as soon as a bulging is noted. 

Angina. — This may be either a severe congestion of the mu- 
cous membrane of the throat, a severe tonsillitis with enlarge- 
ment of the tonsils, a pharyngitis and laryngitis, or a gangre- 
nous condition- of the tonsils. It is not infrequent that scarlatina 
sine exanthemata is at first diagnosed as a simple catarrhal or a 
follicular tonsillitis, as an exudate in the tonsillar crypts is very 
frequent. "Where the exudate is very thick, late in the eruptive 
stage, the chief organism is the diphtheria bacillus. The diph- 
theritic form usually reaches its height at the end of the first 



CONTAGIOUS DISEASES. 383 

week, and the symptoms and appearance of the throat are the 
same as in uncomplicated diphtheria. 

Adenitis. — The inflammation of the lymph nodes may be 
quite severe and suppuration may occur. This enlargement of 
the glands at the angle of the jaw and of the neck may be enough 
to cause pressure on the larynx and dyspnea, or the strepto- 
coccic invasion of the cellular tissue of throat and larynx, 
sufficient to necessitate intubation. I have had such a case un- 
der mj^ observation. 

The child had a severe scarlatina with first a double suppurative otitis 
media, then an albuminuria, followed by a membranous angina and an ob- 
structive laryngitis. This condition necessitated an intubation which re- 
lieved the symptoms for a time only, the obstruction from cellular infiltra- 
tion both above and below the tube being so great as to make the removal 
of the tube imperative. This was done with great difiiculty. Dyspnea be- 
ing decided and relief necessary to prolong life, tracheotomy was done. A 
bronchopneumonia developed shortly after and death from heart failure 
relieved the sufferings of the child. 

Arthritis. — A streptococcic inflammation of the joints is some- 
times seen, formerly diagnosed as a scarlatinal rheumatism. It 
is a synovitis of streptococcic origin. Surgery may be found 
necessary where purulent effusion in the joint is present. Fixa- 
tion of the joint is imperative. 

Kidneys. — The kidneys are involved in scarlatina in a large 
percentage of cases, the symptoms appearing usually from the 
end of the second to the middle of the fourth week of the dis- 
ease. A diminution in the quantity of the urine, edema of the 
eyelids, face and ankles is noted, and an examination of the urine 
shows all the abnormalities found in the urine of an acute neph- 
ritis. Uremia may occur in the severer forms of nephritis. 

Frequent or daily examination of the urine from the begin- 
ning of the second week is desirable, as albumin will often be 
present before symptoms of the nephritis appear. 

Lungs. — A bronchitis is not as frecjuent a complication in 
scarlatina as in measles, but it sometimes occurs. Bronchopneu- 
monia is more often seen, especially in those cases in which the 
streptococci are present in large numbers. 

Other complications occasionally occurring are an endo- 



384 THE DISEASES OF CHILDREN. 

carditis, in those cases of streptococcic synovitis especially; a 
myocarditis in severe septic infection, as in gangrenous sto- 
matatis; meningitis in the course of the disease or following a 
mastoid involvement as a complication of otitis media; convul- 
sions, either as an initial symptom or during the course of the 
disease; an irritable condition of the stomach, recurrent vomit- 
ing, anorexia, diarrhea. Vomiting as the first symptom, occurs 
quite regularly. As seguelce there may be a chronic tonsillitis 
with enlargement, and perhaps the development of adenoids; 
deafness, already referred to ; mastoiditis ; chronic nephritis ; and 
endocarditis. 

Diagnosis. — In the irregular forms of scarlatina with but 
little rash, which is of very short duration, the diagnosis may 
be very uncertain, as in the case of gangrenous tonsillitis re- 
ferred to, or not suspected at all, and not made until desquama- 
tion begins. 

Diagnosis must be made from erythematous rashes, either 
caused by external irritants or from the action of certain drugs 
or poisons taken internally. Belladonna, quinin, salicylic acid, 
bromides, or veronal are among the drugs causing rashes. In 
these rashes there are practically no symptoms except the rash. 
Scarlatinaform rashes may follow the injection of the serums 
especially diphtheria antitoxin. 

The typical cases, however, should be easy of diagnosis. The 
associated symptoms are characteristic, vomiting, fever, typical 
rash, sore throat and strawberry tongue. 

Prognosis. — In uncomplicated cases this is good. Holt gives 
the general mortality from 12 per cent to 1-t per cent in uncom- 
plicated cases, and cases under five years from 20 to 30 per cent, 
others give the mortality in several epidemics as 3 per cent. 
Hence, the prognosis is greatly influenced by the occurrence of 
complications and by the age of the patient. 

Treatment. — Prophylaxis. Empirically we have learned that 
scarlatina is much less contagious than measles, and that the 
contagium is very much longer lived, hence the special indica- 
tions are strict isolation and quarantine of every case of scarla- 
tina, and most thorough disinfection after dismissal of the case, 
of room, bedding, dishes, clothing, etc. Isolation should begin 



CONTAGIOUS DISEASES. 385 

as soon as it is known the child has been exposed to scarlatina, 
even though the exposure has been during the incubation stage, 
when it is believed the least danger is present. Other children 
in the house should remain away from school, and should not 
be sent away from home in order to continue at school because 
of the possibility of late development of scarlatina in them. AH 
intercourse between the sick room and the rest of the house 
should be prevented, and the physician should protect himself 
by a long gown before entering the room and cover head with 
head gauze or cap. The gown should be taken off after leaving 
the room. The hands and face should be then carefully washed. 

Quarantine should be prolonged during the entire stage of 
ciesquamation, and not until the feet and hands are entirely free 
from roughness and scales should it be raised. The persistence 
of the discharge from an otitis or a chronic nasal discharge or 
pharj^ngitis is sufficient ground for maintaining the quarantine. 

Placarding of houses is most important and this regulation 
will be made a law if the physicians of a community demand it. 
The medical inspection of public school children is a measure 
which will prevent many epidemics of scarlatina and measles, 
as the early recognition of the sore throat of one, catarrhal symp- 
toms and buccal eruption of the other, will be enough to remove 
the child from the class long enough to have the tentative diag- 
nosis confirmed or disproved. Attention to details in the choice 
and conduct of the sick room should be given by the physician. 
A room as cheerful as possible should be chosen, but removed 
from the rest of the house, on the top floor, or at the back, near 
enough to the toilet and bathroom as not to necessitate the carry- 
ing through all the halls of the discharges, etc. All unnecessary 
hangings and the carpet should be removed. A tub should be 
provided in the room containing enough antiseptic solution 
(1:2000 bichloride or 1:20 carbolic acid solution), in which all 
bed linen and clothes can be soaked before they are removed to 
be washed. They should then be boiled separately from the rest 
of the wash. Scraps of old sheets or tablecloths or squares 
of gauze are best used for handkerchiefs, and burned after- 
ward. 

A sheet should be hung from the top of the door frame out- 



386 THE DISEASES OF CHILDREN. 

side the door to lessen air communication with the rest of the 
house. 

After desquamation has begun general inunction of the skin 
is of service in preventing the dissemination of the scales. Plain 
vaseline is as good as anything as it is doubtful if any anti- 
septic of sufficient strength to be bactericidal will not be strong 
enough to cause the irritation of the skin; 2 per cent of carbolic 
acid can be added if there is much itching, but it must not be 
used very strong. 

Toys and books should be destroyed after the child has been 
removed from quarantine. 

The room should be carefully fumigated and the walls and 
woodwork wiped down with a 1 :1000 solution of bichloride of 
mercury or 1 :20 solution of carbolic acid. 

Symptomatic Treatment. — As there is no specific for scarlet 
fever the treatment is largely symptomatic. 

Fever. — For hyperpyrexia coal-tar products should not be 
used but hydrotherapy employed without any hesitation. The 
sponge bath or wet-sheet pack can be used without trouble, and 
in spite of remonstrance from the family. During the bath 
at a temperature of 85° F. or 90° F., the circulation should be 
watched, especially of the hands and feet, and hot-water bags 
applied to them if they are persistently cold. A continuous 
temperature of 103.5° F. usually requires attention, but the 
effect of the temperature on the patient should be the guide. 
Gentle friction of the skin should be used while the bath is being 
given, A little alcohol in the water for sponge bath is ad- 
vantageous. It is well, with a tendency for the temperature 
to run high, to place an ice bag to the head, which usually 
materially assists in the control of the fever. 

Kidneys. — Water should be given at very frequent intervals 
from the onset of the symptoms in order to keep the kidneys 
flushed. This is especially so in the cases with severe angina 
when the mixed infection is apt to be a feature. The following 
is of benefit : 

1$. Liq. ammonii acetatis 3SS 
Spiritus setheris eomp. ^i 
Aquae destillat. q. s. ^iv 

M. Sig. One teaspoonful every 3 hours. 



CONTAGIOUS DISEASES. 387 

Boivels. — If the vomiting is not persistent, an initial dose of 
calomel of 1 to 3 grains is of great benefit and should be given 
as soon as possible. If not effectual in obtaining a free evacua- 
tion it should be followed by 2 or 3 drachms of castor oil. Daily 
evacuations, which must be insisted upon, can probably be ob- 
tained by using an enema or glycerine suppository. An occa- 
sional drachm-dose of cascara aromatic, or syrup of tamarinds 
or milk of magnesia may be needed during the bed stage. 

Owing to the great amount of extra work thrown upon the 
kidneys, the diet should be such as will not increase elimination 
by the kidneys, hence a milk diet is decidedly the best. A mixed 
diet, with no meat, can be begun after complete subsidence of 
the fever and rash. 

A very good rule to follow is to keep the child in bed for one 
week after the disappearance of the rash, and then to let it get 
out of bed for a gradually increasing time each day, being well 
protected from exposure if not entirely dressed. 

Nose, Throat and Ears. — Antiseptic spray, Dobell's solution, 
normal salt and boracic acid solution in equal parts, warmed 
to 110° F., can be used as either a spray, douche or snuffed up 
the nose, in cases with profuse nasal discharge, or used as an 
irrigation in angina. The danger of forcing fluids through the 
Eustachian tube into the middle ear and causing an infection 
should be remembered. Nasal irrigation with fountain syringe 
is recommended in smaller children. 

Kegular, four-hour interval irrigation of the middle ear when 
the drum has ruptured with warm boracic acid solution should 
be carefully done, the ear dried, and powdered boracic acid 
insufflated into the middle ear. Paracentesis of the drum should 
be done if an examination of it shows it to be bulging, in order 
to obtain free and prompt drainage. This should be done under 
a general anesthetic always, as the shock to the child from the 
pain and being held is too great to have it done without. Gas 
anesthesia is quick and safe and is recommended. 

Soreness of the throat is a prominent symptom at the onset, 
and cold applications are very serviceable. A small, wet flannel 
is folded and placed next the throat and covered with a wider, 
dry piece of goods. Crushed ice fed to the patient is sometimes 



388 THE DISEASES OF CHILDREN. 

found to be grateful to the throat. The tendency to adenitis 
may be largely controlled by the cold, wet pack. 

For the nervousness and restlessness which is often a decided 
feature in the early stages of the eruption, the following can 
be safely used in a child of five years : 

IJ^ Strontii broinidi 5iii 

Cliloralis 3iss 

Syr. limonis '^\ 

Aquae destillat. q. s. 3iii 

M. ft. sol. 
Sig. One teaspoonful every 3 hours as needed. 

Heart. — The circulation should be watched closely. The ten- 
dency is to have a much-increased pulse rate and the first evi- 
dence of flagging in its quality should be met by the adminis- 
tration of strychnia, whisky and probably by digitalis. Digitalis 
can be given in the fat-free tincture, in 5 drop doses. If whisky 
is used, only an article of known value, or one which has been 
bottled in bond, should be used. Strychnia can be given in 
1/150 grain doses, and if used for some time the child watched 
carefully for twitchings which may develop if it is used too long. 

During convalescence iron is indicated in some form, and if 
there is an indication of kidney involvement, Basham's mixture 
is serviceable, in % to 1 teaspoonful doses, w^ell diluted, three 
or four times a day. 

Severe adenitis is best treated by the application of ice 
cloths or an ice bag. No virtue can be found in the so-called 
mud preparations, and only great discomfort is given the patient 
when they are applied. 

Too much emphasis cannot be laid upon the importance of 
fresh air throughout the entire course of the disease. Protect 
the bed from draughts, plenty of coverings, and keep the win- 
dows open, an open fireplace is to be preferred greatly to a 
gas fire, closed stove or furnace heat. 

The serum treatment has been recommended, antistreptococcic 
serum . as a routine and the antidiphtheritic serum in the true 
diphtheritic anginal cases. 



CONTAGIOUS DISEASES. 389 

VARICELLA. 

Synonym. — Chicken-pox. 

Definition. — A specific, infections and contagions ernptive 
disease common to childhood. It is characterized by a rash 
which appears as a macnlopapnle, followed by a vesicle, the 
latter drying and falling off as an encrustation or scab. 

Etiology. — The specific organism has not been isolated, but 
it is highly contagions and can be carried by a third person. 
It is contagions throughout the eruptive stage, the scales being 
capable of transmitting it. Age is an important factor. It 
occurs chiefly in children under 10 years of age, being rarely 
seen in adults. It has no relation to small-pox and one does not 
protect from the other. 

Symptoms. — Period of incuhation, invasion or prodrome, 
eruption and desquamation. 

The incuhation period is from 10 to 16 days, the average pe- 
riod being about 12 days. There are no symptoms common to 
this period. 

Invasion. — There are few prodromal symptoms, in the major- 
ity of cases the rash being the first symptom. Frequently the 
child may be quite restless during the night and may itself 
call attention to the rash when dressing in the morning. There 
is apt to be a slight rise in temperature. Digestive disturbances 
are rare, though there may be vomiting. 

Eruption. — The first spots noticed are usually upon the 
chest, and the margin of the hair and face. If seen early the 
rash will appear as a reddish blotch, followed soon by a papule, 
upon the apex of this appearing a tiny vesicle which gradually 
enlarges in size. The rash rapidly spreads to other parts of the 
body, appearing in successive crops for -18 hours, so that at the 
end of this period there are present all stages of the eruption 
at the same tim.e. The papule usually is about one-fourth of 
an inch in diameter, the vesicle being slightly smaller, having 
the appearance of resting upon a red base. Occasionally the 
vesicle will develop upon the skin without the primary macule 
or papule, looking like a drop of water on the skin. The fluid 
of the vesicle at first is clear, but in a fcAv hours it is cloudy in 
color. The vesicle is unilocular and Avhen pricked upon the top 



390 THE DISEASES OF CHILDREN. 

the fluid escapes. Infrequently the vesicles are unbilicated, in 
this respect resembling the small-pox vesicle. As the vesicle 
dries the scab forms. Sometimes the vesicle becomes infected 
and a good deal of cellular infiltration may occur, with ulcera- 
tion into the true skin, and resulting pitting scar. Coincident 
with the appearance of the exanthem, the enanthem appears on 
the mucous surfaces, the mouth, vulva and prepuce. 

The eruptive stage lasts from three to four days, when all 
the spots are usually scabbed over, the scabs becoming separated 
in from two to three weeks. 

Systemic Symptoms. — The temperature rises, though it is ex- 
ceptional to find it very high. It does not run a regular course, 
and is rarely over 102.5° to 103° F. During the fever the 
papular and vesicular stages, the child is restless and peevish, 
complains frequently of itching and burning, and the tempta- 
tion to scratch is very great. No digestive disturbances are 
seen, as a rule, unless there is the initial vomiting, which does 
not recur. 

Desquamation slowly proceeds during the last two weeks of 
the disease, a few scales dropping off from day to day, usually 
leaving a dry base, lighter in color than the surrounding skin. 
Sometimes there is a decided ulceration, in case the vesicle 
has been infected. 

Complications and Sequelae. — The only complication of mo- 
ment I have ever seen was an erysipelas, which was very severe 
and extensive, and which proved fatal. 

Varicella gangrenosa has been reported as a complication. 
This is extremely severe and usually fatal. Vlceration at the 
site of one or more of the vesicles may take place, extending into 
the true skin, and these always leave a pitting scar. It is quite 
usual to find one or more of these pits somewhere upon the body. 

Hemorrhage may rarely occur in the vesicles. Second at- 
tacks are practically never seen. 

True nephritis may be a complication, albumen is frequently 
temporarily present. 

Diagnosis. — The chief disease to be diagnosed from is small- 
pox of a mild type. Corlett gives the following diagnostic 
points: {a) Varicella has mild prodromal symptoms, and 



CONTAGIOUS DISEASES. 391 

they may be absent altogether, (b) The eruption appears on 
the trunk, where it is more abundant than on the face and 
hands, (c) The multiform character of the eruption, its super- 
ficial position, comparable to drops of water sprinkled over the 
skin, and its appearance on the same region in successive crops. 
(d) Its mild constitutional symptoms and short duration, the 
disease usually terminating in 5 to 14 days, (e) It is mildly 
infectious and always gives rise to the same disease. 

Prognosis. — In uncomplicated cases is always good. 

Treatment. — Isolation is the principal consideration. Atten- 
tion to the bowels is very necessary with an initial dose of 
calomel. A simple* diet should be given, preferably only liquid 
or soft food, according to the age of the child. Confinement 
to bed is necessary only during the febrile stage. If the child 
is old enough it should be warned against scratching, if too 
young its hands should be covered in order to prevent it. A 
2 per cent carbolic acid vaseline ointment will prevent itching 
and make the patient more comfortable. The bowels and diges- 
tion must be watched and daily baths given. 

VACCINATION. 

Synonym. — Coivpox. 

Definition. — This is an eruptive disease in the human race 
caused by the introduction into the system of the small-pox 
Adrus or lymph, obtained from one of the vesicles. 

History. — Edw. Jenner, in May, 1796, after observation of 
cases of cowpox in milkers and the immunity Jt gave those con- 
tracting it, performed the first vaccination on the human subject. 
The first vaccination in America was performed in 1800 in 
Cambridge, ]\Iass. Statistics prove what a boon to humanity 
has been the discovery of vaccination. 

Technic. — A child should be vaccinated before the end of its 
first year, and revaccinated at the end of every seven years. 
Statistics have shown that in cases of small-pox occurring in 
persons giving a history of a successful vaccination, the vac- 
cination was usually done more than seven years previously. 

Vaccination should not be done in a child who is acutely ill 
or who has a skin lesion, or in a child sufferino- from anv of the 



392 THE DISEASES OF CHILDREN. 

diseases of malnutrition. The occurrence of an epidemic of 
small-pox is the only reason for not making these exceptions. 

The site of the vaccination has been the subject of much 
comment, whether it should be done upon the leg or the arm. 
Owing to the possibility of an infection occurring after the 
operation and the greater number and size of the inguinal 
lymphatics, the choice of the arm should always be made. The 
point of selection is just above the insertion of the deltoid 
muscle upon the arm least used, the left arm in the right handed, 
and vice versa. 

The selection of the virus should be made with care : The scab 
from a human vaccination scar should never be used because of 
the danger of infection. Only bovine lymph should be em- 
ployed and the glycerinated lymph is best, as this form of 
lymph is sterile and there is no chance for it to become con- 
taminated with bacteria. The glycerinated lymph is furnished 
by reliable firms in sealed capillary tubes and in hermetically- 
sealed tubes containing glass or ivory points, upon which is 
smeared the virus. 

The operation should be considered strictly a surgical pro- 
cedure and performed with great care and in a surgically, 
cleanly manner. The arm is bared, washed with soap and water, 
and dried, but no antiseptics should be used. The skin should 
be scarified over an area one-half inch square, and the lymph 
rubbed into this and allowed to dry. A sterile, medium-size, 
cambric needle can be used for the scarification, care being 
taken not to mal|^ the scratch deep enough to draw blood, or 
the end of the point can be used to rub off the upper skin. It 
usually takes 15 or 20 minutes for the lymph to dry. To facil- 
itate the child's having its sleeve pulled down, cut a piece of 
light cardboard, round, II/2 to 2 inches in diameter, and then cut 
it half through. The cut edges are slipped by each other and 
a cone formed. This is held in place by narrow strips of ad- 
hesive plaster. When the lymph is dry the improvised cone 
shield can be removed. 

The after-care of the vaccination area should be mentioned. 
Bad results are due to infection transmitted to the wound after 
the vaccination has been performed, and not to contaminated 



CONTAGIOUS DISEASES. 393 

virus, provided the virus from a reliable maker has been selected. 
After the wound has dried it usually needs no attention or pro- 
tective dressing, unless it be one or two layers of gauze bandage. 
A typical vaccination will run its course without breaking 
down or becoming moist. If it does become moist and the 
sleeve sticks to it a shield which is perforated, has a wide base 
to rest upon the arm, and large enough to make no pressure on 
the vesicle, should be applied as a protection. If the wound 
becomes infected with pus formation it should be treated sur- 
gically as other wounds. 

Normal Course. — Upon the third or fourth day following a 
successful vaccination, the area scarified becomes red, and slightly 
indurated and raised. Upon this area, on the next or second 
day following, a vesicle forms, slightly smaller than the red area, 
which is decidedly umbilicated. The reddened area spreads to 
half an inch or more in width, with perhaps a congested area, 
much lighter in color, extending 2 or 3 inches or encircling 
the entire arm. The vesicle at first is pearly white, gradually 
changing in color to a yellow or brownish color, and then dry- 
ing up, if normal, without rupture. A distinct scab forms 
which gradually loosens, leaving a dry scar, slightly depressed, 
and containing a number of smaller depressions or pits. 

The time usually required for a ' ' take ' ' is as follows : Fourth 
day, indurated red area or papule ; sixth day, vesicle ; tenth 
day, pustule; twelfth day, scab; fifteenth to eighteenth day, 
scab separates, leaving the scar. 

Symptoms. — Coincident with the formation of the vesicle there 
may be a rise of temperature from 3° to 5°, 101° to 103° F., 
and may last until the formation of the scab. The arm feels 
swollen and stiff, and there may be some glandular enlargement 
in the axilla, and pain. Around the vaccination area several 
small pustules may form which are superficial and leave no 
scars. 

Complications. — The chief complications which occur are those 
referable to the skin, and the most striking is a general vaccinia. 

This is an eruption which is like that seen in some cases (and 
referred to above) occurring around the site of the vaccination, 
pustular in character, appearing about the tenth day, and if 



394 THE DISEASES OF CHILDREN. 

closely watched passing through the papular, vesicular and 
pustular stages. 

A general erythematous eruption is more frequently seen, 
resembling a measles eruption. This may occur only on the 
trunk or around the waist, buttocks and thighs. It is hot, 
slightly raised and itches a good deal, and usually is of short 
duration, lasting from a few hours to two or three days. 

An urticaria, similar to that complicating the injecting of 
any of the sera subcutaneously, may occur. 

A cellulitis about the vaccination area is a common occur- 
rence. The entire arm may be involved, it is greatly swollen, 
very tense and painful, the arm is very ''sore." In these cases 
the vesicle is apt to rupture, and the whole area occupied by the 
vesicle may become gangrenous. 

In the colored race, especially, and frequently in the white, 
a keloid forms in the scar tissues left after the separation of 
the scab, which may become raised above the surface of the 
skin, and is firm and glazed. 

An adenitis sometimes develops, in the axilla or groin, the 
glands being enlarged and tender during the inflammatory 
stage of the ' ' take. ' ' 

The distinctness of the vaccination scar is not sufficient evi- 
dence of the persistence of immunity conferred by a single vac- 
cination. It is frequently found that a typical ''take" is re- 
corded in a person with an excellent and typical mark if more 
than seven years have elapsed since the first vaccination. 

A natural immunity does not exist. If a primary "take" 
has not been obtained there has been some fault in the technic, 
and the operation should be repeated until successful. I have 
revaccinated myself until on the fifth attempt a successful 
"take" was obtained. 

VARIOLA. 

Synonym. — Small-pox. 

Definition. — The most contagious of the exanthemata char- 
acterized by a sudden onset, high fever, a rash, going through 
regular stages of development, viz., papule, vesicle, pustule, scab, 
desquamation and cicatrices. If one unprotected by vaccina- 
tion is exposed to the contagion he is practically always attacked. 



CONTAGIOUS DISEASES. 395 

Etiology. — It is believed by Councilman and others that the 
organism, the cause of small-pox, has been isolated, though it 
has not been cultivated on artificial media. These bodies are 
described as occurring "in epithelial cells, in the nuclei and 
free." 

The disease in contracted by direct contact and the contagion 
can be carried upon the clothing, etc. The most virulent car- 
rying medium is the pus from the pustules, and the scabs which 
later form, and the excreta. The organism gains entrance to 
the body through the mucous membrane. The contagion can be 
carried through the medium of the air. It is contagious from 
the first symptom until desquamation is complete. 

Segregation in cold weather increases the freciuency of small- 
pox. 

Symptoms. — Several types are recognized, variola vera, which 
may be confluent or discrete; hemorrhagic; varioloid or modified 
form. 

The ordinary form has the following periods, invasion, incu- 
hation, eruption and desquamation. 

Invasion. — According to different observers the stage of inva- 
sion lasts from 8 to 20 days, the average being probably 15 days. 
There are no symptoms to this stage. 

hicuhation. — The symptoms of this stage vary according to 
the age of the patient. In the young it is frequently ushered 
in by a convulsion, nausea and vomiting. In the adult, there 
may be a chill, instead of the convulsion. There is regularly 
a rapid rise in temperature, usually reaching 104° F., without 
much variation, severe headache and pain in the back in the 
region of the loins. This pain is perhaps the most prominent 
symptom. The bowels may be disturbed, but not regularly 
so. The pulse is consistently rapid. 

Eruption. — On the third day, sometimes on the second, a 
macular eruption appears on the forehead, at the margin of the 
hair particularly, face, wrists and forearms, and neck, which by 
the fourth day is decidedly papular. The papules soon appear 
on the extremities, palms and soles, and in less numbers on the 
body. These have a distinct shotty feel. The first day they may 
be difficult to diagnose. It quickly spreads to the rest of the 



396 THE DISEASES OF CHILDREN. 

body. On the summit of the papules vesicles form about the 
fifth day, which gradually change to pustules by the tenth day, 
and by the fourteenth day these have become encrusted, with a 
shedding of some of the crusts. The desquamation proceeds in 
the order of the appearance of the rash. 

An enanthem forms coincidently with the exanthem. 

The vesicles have a decided umbilication or depression, which 
remain until the pustules form. If pricked these vesicles do not 
collapse because of the reticular division inside them. After 
the scabs fall off the skin is left slightly discolored, and according 
to the depth of the ulceration a pit or depressed scar remains. 
There may be a coalescence of the pustules on the face, or they 
may rupture, the pus drying upon the skin forming a crust 
over the entire face. 

The fever runs a fairly typical course, sudden of onset, reach- 
ing 104° or even 106° F. the first day, and remaining up until 
the eruption appears, when it gradually recedes to normal or 
very slightly above, about the fifth day. It remains down then 
until the pustules are formed, about the tenth day, when it 
reaches usually the height it was at first, or even higher. This 
is the secondary fever. Fever persists during the pustular 
stage, gradually falling ; symptoms abate, the restlessness, back- 
ache, headache, etc., improve. 

During the septic temperature there is a return of these symp- 
toms to a certain extent, and they may be very severe. Absorp- 
tion may be enough to cause septic symptoms of gravity, the 
patient being drowsj^ or even delirious. 

In the confluent variety, in which there is a coalescence of the 
vesicles and pustules, all of the symptoms are more severe. 

Hemorrhagic Variola. This form is the most severe. There 
is an extravasation of blood in the vesicles, either as a primarj^ 
lesion or the blood appearing during the pustular stage. 

Varioloid. This is a modified form of small-pox occurring in 
individuals in whom the immunity from a previous vaccination 
has about disappeared, and is as contagious as variola, a severe 
true small-pox may be caused by it. In varioloid there is very 
little eruption and no secondary fever, all of the symptoms being 
very much less severe, and of shorter duration. 



CONTAGIOUS DISEASES. 397 

Complications. — These are few, as a rule. The pustules may 
cause deep ulceration and consequent pitting and permanent 
scarring of the sli)i. 

There may be a catarrhal or purulent inflammation of the 
middle ear. The eyes may be involved, an ulceration of the 
cornea being sometimes found. A Janjngitis is not infrecjuent, 
and an extension downward causing a bronchopneumonia or 
edema of the pharynx and larynx may occur. Furunculosis 
and ad i nit is occasionally occur during the convalescence. Ar- 
thritis may complicate the disease. 

Diagnosis. — Until the appearance of the rash the diagnosis 
cannot be positively made, but when a sudden high temperature 
is seen with severe headache and backache, in the absence of an 
epidemic of grippe, small-pox should be suspected. The most 
freciuent disease with which it is confused is chicken-pox. The 
great infrequency of chicken-pox occurring in adults should 
cause variola to be suspected in every vesicular eruption. The 
discrete eruption in varioloid and the mildness of the general 
symptoms are deceptive. 

Prognosis. — Vaccination and age influence the prognosis 
greatly. The mortality in late epidemics has been very light. 
In the unvaccinated young the prognosis is always grave. The 
extent of the rash -upon the face is a good guide as to the 
severity of the attack. The hemorrhagic form is very fatal. 
The occurrence of any of the complications makes the prognosis 
less favorable. 

Treatment. — PropJiijJaxis. — Vaccination, isolation and disin- 
fection are the best methods of prevention. It is absolute by 
vaccination, the immunity thus conveyed lasting in its fullest 
from five to seVen years. Eevaccination should be practiced. 

No city is safe from epidemics without the erection of an 
isolation hospital, removed beyond the city limits. The care 
of these cases should be left to the city authorities, and prompt 
report of cases in the city made to the Health Board should be 
required. 

Disinfection should be most thorough, the formaldehyde, per- 
manganate of potash method being very eflicient. Bedding 
should be destroved and the room thorou2:hlv overhauled and 



398 THE DISEASES OF CHILDREN. 

cleaned. Vaccination of every person known to have been ex- 
posed to a case of small-pox should be insisted upon, and its 
spread thus limited or stopped entirely. 

LocaL^The confinement of the patient in a room in which 
only red rays of light are admitted has been shown to be 
efficient in limiting the inflammatory reaction in the pustules, 
and consequent limiting of the amount of pitting or scarring. 

The pain and burning in the skin from the eruption is best 
relieved by the local application of soothing, antiseptic lotions 
upon a mask cut from gauze. The following is of benefit: 

I^ Acidi carbolic! puri liqiiefacti 3iss 

Zinci oxidi pulv. 3i 

Aquae destillatse q. s. ^iv 

M. ft. sol. 
Sig. Saturate cloths and apply to face or other parts, 

at frequent intervals. 

or 

R. Ichthyol ammon. sulph. 3vi 

Aquffi destillat. ^iv 

M. ft. sol. 
Sig: Locally. 

In the pustular stage the following is recommended : 

IJ Acidi carbolic! TUxv 

Aq. calcis 

01. Olivse aa ^ss 

M. Sig. Locally. 

In the event of eye involvement, pus exuding from the con- 
junctival sac, and danger to the cornea from ulceration being 
present, they should be frequently irrigated with a 5 per cent 
boracic acid solution, and an occasional drop of atropia solution 
introduced. Five per cent argyrol solution will be of benefit in 
the purulent condition sometimes seen. 

Fever is best combated, both primary and secondary, by 
hydrotherapy, sponge bath, wet pack or tub bath. The use of 
baths during desquamation, followed by oil rubs, hastens this 
stage. The patient should be kept strictly in bed during the 
entire eruptive stage. 

For the great pain in the back and head during the stage of 



CONTAGIOUS DISEASES. 399 

incubation, an opiate may be necessary. The coal-tar deriva- 
tives should be used with great caution. 

Stimulation may be needed at certain stages, whisky, digitalis 
or strychnia. 

The diet should be fluid, jireferably milk, and broths Avith 
plenty of water. 

Bromide and chloral can be used for the great restlessness. 

PERTUSSIS. 

Synonym. — ^Yllooping-cough. 

Etiology. — The organism which is now believed to be the spe- 
cific cause of pertussis, was discovered by Bordet, working in 
collaboration with Gengou, in 1905, and is a small coccibacillus 
resembling the bacillus of influenza in size and shape. It is 
usually found in the viscid exudate expectorated from depth of 
bronchi during paroxysms of coughing. The organism may be 
stained with weak solutions of fuchsin and does not take the 
Gram stain. It grows best in a media made of equal parts of 
defibrinated blood (human or rabbit) and 3 per cent agar con- 
taining small quantity of potato extract and glycerine. It also 
grows fairly well on serum "bouillon or blood bouillon, but on 
ordinary culture media only after it has been cultivated in the 
laboratory for some time. 

AYhile not universally recognized, the identity of Bordet 's 
bacillus as a causative factor of whooping cough is fairly well 
established. The strongest evidence which we have is perhaps 
the agglutination and complement fixation reactions first ob- 
served by Bordet and afterAvards confirmed by numerous in- 
vestigators. Further evidence is afforded by an experiment of 
Bordet AA'ith vaccines prepared from this organism. Twenty 
children AAdio had been exposed to Avhooping-cough AA'ere giA^n 
prophylactic injections and in every case developed unusually 
A'iolent cases, clearly indicating that a profound negatiA^e phase 
had been produced. Experiments on loAver animals to determine 
the pathogenesis of this organism haA^e been unsatisfactory. 
Ordinary laboratory animals are not infected b}^ inoculations, 
but Klimenco and Fraenkel claim to haA^e produced typical 
Avhooping- cough in monkeys bA^ injections of this organism 



400 THE DISEASES OF CHILDREN. 

Klimenco also believes that similar results were produced in 
puppies, but this latter work has been greatly questioned. 

Although inoculations with small quantities of this organism 
into animals are not followed by the development of an infective 
process, larger doses kill animals with symptoms of profound 
toxemia, evidently due to toxins generated during growth on 
media. Toxins extracted from cultures of this organism in- 
jected into peritoneum of guinea-pig produce hemorrhagic and 
exudative lesions. Injected subcutaneously they result in edema 
and necrosis. Inoculated into the eye of a rabbit they produce 
necrosis of the cornea. Bordet calls attention to the fact that 
an analogous necrosing influence may be observed on the surface 
of bronchi of affected children and believes that the manifesta- 
tions of this disease are due to lesions of the cellular lining of 
the bronchi, resulting from the action of this irritant poison. 
This coincides with the clinical fact ' Hhat whooping-cough ceases 
to be a part of the clinical picture immediately previous to 
convalescence at which time germs become rare in the exudate." 

Its habitat is the nose and throat, and is directly transmitted 
from one child to another. It is not necessary for the infecting 
child to cough to transmit the infection, as it can be carried 
through the air from ordinary breathing, but the children must 
be fairly close together, and also by toys, clothing, etc. It is 
both endemic and epidemic. It is contagious at any time in its 
course. No age is exempt, though it is much more common 
between the ages of one and ten years, the majority of cases 
occur under three years old. The youngest child I have seen 
with it was six weeks old, the attack proving fatal. Cases much 
younger have been reported. One attack does not confer im- 
munity in every case. My oldest child had two distinct attacks. 
I have seen one grandfather over 60 years of age with a severe 
attack. 

Pathology. — There is a catarrhal condition of the mucous 
membrane of the nose, pharynx and larynx, and especially the 
trachea, with very frequent involvement of the bronchi as a 
complication. In severe cases there may be a true or a com- 
pensatory emphysema. 

Symptoms. — The incuhation is generally about two weeks. 



CONTAGIOUS DISEASES. 401 

There is a cough which shows no tendency to improve, and in 
spite of ordinary remedies grows more persistent, and without 
signs in the chest to account for it. This is usually described 
as the catarrhal stage, and lasts from one to two weeks, followed 
by the spasmodic and ivhooping stage and the stage of recession. 
In the catarrhal stage there may be a slight puffing of the lower 
eyelids, some loss of appetite and disinclination to play, as 
exertion tends to increase the cough. During the last of this 
stage the cough becomes more paroxysmal in character, the child 
going some time between the paroxysms without coughing. 
The paroxysms become spasmodic, they begin with a slight, 
hacking cough, which gradually becomes more severe, and ends 
in a long-drawn, deep inspiration accompanied by a crowing 
sound, which is the characteristic "whoop" from which the 
disease took its name. Once heard, there is no mistaking the 
sound. The child loses its breath for a moment and gets very 
red or dark red in the face, the eyes and nose run ; the child runs 
to some one or grasps a fixed object for support, and with the last 
deep inspiration and whoop, may vomit the contents of the stom- 
ach, and mucus from the trachea. After the paroxysm is over the 
child falls back exhausted, its color gradually returns, and it, 
may shortly resume its play. If the paroxysms are repeated 
very frequently there may be a deep injection of the superficial 
vessels in the conjunctiva or a subconjunctival hemorrhage. 
Between the paroxysms the child 's face is puffy and bloated under 
the eyes, due to lymphatic stasis. There may be an ulcer under 
the tongue in children with lower teeth. 

Paroxysms are brought on by severe exercise, eating, often a 
drink of water, excitement, and usually recur every half hour 
to an hour in the 24, but there are often many more than this. 
If a count can be kept of the number of the paroxysms, day 
and night, the effect of medicinal treatment can best be noted, 
as a lessened number of paroxysms would be the first improve- 
ment. 

After about two weeks, or more, of the severe paroxysms their 
frequency and severity both become less, and in this period of 
decline, the child shows a general improvement. It does not 
vomit now with each paroxysm and sleeps longer at night. 



402 THE DISEASES OF CHILDREN. 

During this stage, if the child acquires a fresh "cold," its 
cough partakes of the same paroxysmal nature, and, in fact, for 
some weeks afterward. 

Complications. — The most frequent is a bronchitis, though a 
bronchopneumonia is often seen. An emphysema may occur in 
very severe cases, which is more or less permanent. From the 
passive congestion, due to bronchial involvement, there are apt 
to be hemorrhages from the nose and into the conjunctiva and 
brain. Hernia may result from the straining at coughing, and 
the rectum may also be forced out in young children. Incon- 
tinence of urine during coughing is not infrequent. Albumen 
and casts may be found in the urine during the height of the 
attack. The simultaneous occurrence of measles and pertussis 
has been often reported. Tuherculosis may have its starting 
point in an attack of pertussis. Convulsions may occur in the 
young. 

Diagnosis is not at all certain, and is most often made by the 
mother and nurse before seen by the physician. A history 
of exposure, and paroxysmal coughing, even without the whoop, 
is sufficient for a diagnosis. In an epidemic one may see severe 
paroxysmal coughs and absolutely no tendency to whoop. The 
diagnosis must be made from tubercular bronchial glands, hyper- 
trophied tonsils and chronic bronchitis. 

Churchill ^ and others have made investigations as to the 
differential blood count during whooping-cough. Comparing 
the lymphocyte count in whooping-cough with a normal count 
of a child at 10 years, which will average 32 per cent, in whoop- 
ing-cough it will run from 34 per. cent to 93 per cent. 

Mosenthal'^ found in "institutional" children the average 
leucocyte count to be 13,850 to 16,391. The percentage of 
polymorphonuclear cells is slightly diminished with a corre- 
sponding increase in the mononuclears. 

During the catarrhal stage of pertussis, an increase in leu- 
cocytes is found, approximating double the normal, and the 
mononuclear cells increased about 5.5 per cent. 

A hyperleucocytosis, with an increase in the percentage of 



^ Journal American Medical Association, 1906, volume xlvi, 1506-9. 
^Archives Pediatrics, November, 1908. 



CONTAGIOUS DISEASES. 403 

mononuclear cells at the expense of the polymorphonuclear, is 
an aid to the diagnosis of pertussis in the catarrhal stage. 

Prognosis. — In very young children the prognosis is always 
grave because of the lack of nourishment, the physical exhaus- 
tion due to the coughing, the tendency to the occurrence of com- 
plications. Too little attention is paid to whooping-cough, as a 
rule, and there are too many wanton and willful exposures to 
it, ' ' that the child may have it while it is young, ' ' for many a 
child dying of pneumonia had whooping-cough as the chief 
factor in the fatality. The more frequent the paroxysms and 
the vomiting, the graver the prognosis. The beginning of an 
epidemic in institutions is greatly to be feared. In the 1902 
census whooping-cough ranked fourth as a cause of death. In 
1906 it caused more deaths than measles or scarlet fever. 

Treatment. — Quarantine of the affected child should always 
be insisted upon, and municipal control of the quarantine should 
be possible. The diet should be in small amounts, and prin- 
cipally of milk, especially if vomiting is a prominent symptom. 
It may be necessary to peptonize the milk, or to give one of the 
predigested foods. 

Fresh air is most essential and the more these children are out 
of doors the better. The room temperature should range between 
55° F. and 60° F. The tendency to bronchitis must be remem- 
bered and the child perfectly protected from draughts. 

Local and Medicinal. — A great number of drugs have been 
recommended for pertussis, but no one can be relied upon in 
every case. A much-vaunted remedy is the vaporizing with a 
lamp of one of the phenol preparations. This has been reported 
of service by some, but is a dangerous remedy as carbolic acid 
poisoning is a possibility. The room full of fresh air is decidedly 
more beneficial. 

Internally several remedies are used more generally than 
others, viz., antipyrine, bromide, quinin, codeine, belladonna 
and bromoform. 

Antipyrine can be used in doses of 1 grain to each year of 
the age, up to 3 grains every two hours, with syrup of tolu as 
a vehicle. Quinin can be added to this prescription or given 
alone, up to 3 grains at a dose, or with glycyrrhiza or verba 



404 



THE DISEASES OF CHILDREN. 



santa. Bromide can always be given with either of these 
mentioned. 




Fig. 73. — The whooping-cough belt. (Kihner.) 




Fig. 74. — Rear view of the whooping-cough belt applied. (Kilmer.) 

Codeine is a valuable assistant to any of the above, and can 
be given for its effect. 

Belladonna is probably best given in the form of the fluid 



CONTAGIOUS DISEASES. 405 

extract (i'^ min.) or tincture (2 min.) doses, and it must be 
given for its physiological effect. 

Bromoform is a dangerous drug, because of the difficulty of 
forming a perfect mixture, and the invariable settling of por- 
tions of it to the bottom, and the last two or three doses con- 
taining perhaps a lethal dose of the drug. I have seen three 
children put to sleep for many hours by being given the last 
three doses in the bottle. 

Sior ^ recommends the use of euchinin as a substitute for 
quinin in the treatment of whooping-cough. It is recommended 
in doses of a centigram for each month, and a decigram for 
each year, twice a day, morning and night, given in sugar, milk 
or cold chocolate. It can also be given in suppositories. The 
report of the cases in which it was used showed a cessation of 
vomiting, disappearance of cyanosis and a shortening of the dura- 
tion. 

Dr. T. W. Kilmer has reported a number of cases materially 
benefited and the attack shortened by the wearing of an abdom- 
inal binder, made of linen with a strip of elastic webbing under 
each arm and lacing up the back. He claims for it that the 
paroxysms are reduced in severity and number, vomiting relieved 
and complications less frequent. 

One of the several preparations of chestnut leaves may be used 
with good effect in some cases. 

After the child has ceased coughing it should be given a tonic, 
which will make up the leucocytosis and low hemoglobin Avhich 
is nearly always. present. 

The employment of pertussis vaccine as a prophylactic and 
curative agent has been successfully used. 

As a prophylactic agent two injections are given, 25 million 
the first dose, and in four days fifty million. As a curative 
agent four injections are given at intervals of four days, the 
initial dose being but 25 million. 

PAROTITIS. 

Synonyms. — Mumps, epidemic parotiditis. 
Etiology. — The infecting organism is not known. It is very 
contagious, occurs epidemically as well as in endemics; affects 



iJahrb. fur Kinderhk., 1908, p. 452. 



406 THE DISEASES OF CHILDREN. 

children more often than adults, and chiefly between one and five 
years of age. The contagion is taken into the system through 
the nose or mouth and from close contact. Immunity is con- 
ferred by one attack. 

Symptoms. — The incubation period may be as long as three 
weeks, though it is usually much shorter. There are, as a rule, 
one or two days of lassitude, headache, anorexia, perhaps nausea 
and vomiting. The temperature usually reaches 101° to 103° 
F., and is at its height with the enlargement of the parotid gland. 
The parotids usually enlarge by the fourth day, assuming large 
proportions. The child complains of pain or soreness on swal- 
lowing, stiffness at the angle of the jaw, during and after eating 
the glands usually feel very tense. Acids usually cause great 
pain on swallowing. 

The swelling primarily may not be very great, it is located di- 
rectly under the lobe of the ear and is soft and elastic on palpa- 
tion. It gradually increases in size. After about ten days the 
swelling subsides, the stiffness in the jaws and the pain on swal- 
lowing disappear. 

Complications. — A coincident involvement of the submaxillary 
glands may occur, and there may be a metastasis in the testicles 
or ovaries. In males there is pain in the scrotum, with rise in 
temperature, probably preceded by a chill. The epididymis be- 
comes enlarged and tender, and there may be an involvement 
of the testicle also. With an ovaritis in the female there may 
be pain and enlargement of the breasts. Earache with or with- 
out deafness is often seen. 

Prognosis. — Barring complications the prognosis is uniformly 
good. 

Treatment. — Isolation and protection from exposure are the 
chief indications. The application of heat to the enlarged gland 
is of service in relieving pain. The glands should be covered 
by a piece of dry flannel by carrying the bandage under the 
chin and over the ears, and pinning on the top of the head. 

A laxative should always be given early in the attack, prefer- 
ably calomel followed by a mild saline. 

The diet should be liquid as chewing is usually painful. The 
mouth should be cleansed, and if an orchitis develops the testicle 



CONTAGIOUS DISEASES. 407 

should be supported by hammock-like arrangement made by 
folded towel or a suspensory. Guaiacol in 25 per cent ointment 
has been found serviceable in many cases of epididymitis, giving 
great relief from swelling and pain. 



LA GRIPPE. 

Synonyms. — Influenza, grip. 

Etiology. — This is due to the invasion of the bacillus known 
as Pfeiffer's bacillus, described first in 1892. It is short and 
small, and is found in the secretions from the nose and respira- 
tory tract. It grows on various media to which blood has been 
added. It stains with a carbolfuchsin, 10 per cent solution. 
They appear either in masses or threads of short, thick rods and 
resembles a diplococcus with rounded ends. They are found in 
the pus cells which are present in the nasal secretions later in 
the disease, and at this time the streptococci and staphylococci 
are associated with the Pfeiffer bacillus. It gains entrance 
through the respiratory mucous membrane. 

Epidemics of grip have been described for years and they 
SAveep over the whole country at intervals. It attacks both adults 
and children, but without regularity. More children seem af- 
fected in some epidemics than adults. It may occur at any age, 
and is readily communicable from one person to another. Some 
persons are specially susceptible, having recurrences both during 
the same and different epidemics. 

Pathology. — There is no distinct pathology due to the bacillus 
itself, the pathological changes being chiefly due to the bacteria 
usually found with it. These changes are chiefly a catarrhal 
condition of the respiratory mucous membrane. There may be 
a general enlargement of the lymph nodes and of the spleen. In- 
volvement of any organ or membrane may be present, and tuber- 
culosis may easily be engrafted. 

Symptoms. — Several types are encountered in an epidemic, the 
chief symptoms being referred to the respiratory organs, the mus- 
cular system, the nervous system or the gastroenteric tract. The 
symptoms of each type may be present with those of one being 
most prominent. 



408 THE DISEASES OF CHILDREN. 

In all forms there is apt to be the initial chill, followed by 
fever up to 103° or 104° F, The period of invasion is short 
and generally without special symptoms, not more than a week 
and the incubation a day or so, during which time there is usu- 
ally a dull headache, loss of appetite and irritability. Usually 
the prostration is out of all proportion to the symptoms. 

In the respiratory form there are signs of a cold in the head, 
sneezing, suffusion of the eyes and swelling of the nasal mucous 
membrane. This is followed by a cough and expectoration, with 
probably pain in the chest. The physical signs are those either 
of a bronchitis or a bronchopneumonia, according to the involve- 
ment. The occurrence of pain on inspiration, hurried respira- 
tion and pulse, in the pneumonic ratio, and a rise in temperature 
is usually enough to complete the diagnosis. Usually there is 
more or less muscular aching in this variety also. The bacilli can 
be found in the nasal secretions. 

In the muscular form, following the chill and initial vomiting, 
there is headache and pain in the back, joints and muscles of the 
arms and legs. The child cries when handled and prefers to lie 
in its bed. The fever is quite high, and the pulse accelerated. 

In the nervous form there may be convulsions in the very 
young, with severe headache when the child is able and old 
enough to complain; there is photophobia, great restlessness, ir- 
ritability and nervousness. The prostration is severe and con- 
valescence more prolonged in this type. "Where convulsions are 
present meningitis may be suspected, and a lumbar puncture 
needed to clear up the diagnosis. 

The gastroenteric form is seen of tenest in the younger patients. 
Vomiting is always present, the bowels being also upset with 
thin, green and mucous stools at frequent intervals. There is 
anorexia and coated tongue, with tympany, restlessness and 
fever. 

Complications. — The chief complications are the inflamma- 
tions of the respiratory tract found in all of the varieties. These 
may be caused by the influenza bacillus alone, but usually there 
are associated the pyogenic cocci as well. 

Transient albumen may be found in the urine or a true ne- 
phritis may follow an attack. 



COXTAGIOUS DISEASES. 409 

One of the most frequent complications is an involvement of 
the sinuses contiguous to the nares and the ear. Frontal sinus 
inflammation, middle-ear inflammations and mastoiditis are very 
frequent. During the last epidemic in this section of the coun- 
try these complications were of very frecpient occurrence. 

Malnutrition and athrepsia may follow acute grip in younger 
children. Synovitis may occasionally be seen as a complication. 

Diagnosis. — In the presence of any epidemic the diagnosis is 
usually easy, but in most cases it must be made by exclusion. 
Bacteriological diagnosis is difficult as Pfeilfer's bacillus is not 
easy to find or to grow. 

A complicating tonsillitis or bronchitis makes the diagnosis 
more difficult. The following diseases must often be excluded, 
bronchopneumonia, especially the central type, pyelitis, and ton- 
sillitis. The fact that the prostration in influenza is apt to be 
more profound than in any of the diseases mentioned is an aid in 
differentiation. 

Prognosis. — Uncomplicated, the prognosis is good; with a 
pneumonia it is more or less grave. Severe gastrointestinal com- 
plications are difficult to recuperate from. Convulsions make 
the progress less favorable. 

Treatment. — Isolation of cases of grippe is most important. 
Children should be carefully isolated from other members of 
the family, ill with influenza. Keep the patient strictly in bed, 
in a well ventilated room, giving easily digested and nutritious 
food. Milk, diluted, is the best all-round food, except in the gas- 
trointestinal type, in which the cereal gruels and broths are best. 

An initial dose of calomel, followed by oil, is of great benefit. 

The coal-tar products should be given with the greatest cau- 
tion, and never without one of the diffusible heart tonics is given 
with it, as caffeine alkaloid, 1/10 grain, camphor, 10 minims of a 
10 per cent oil solution, hypodermatically, or strychnia, 1/200 
grain, to a child of two years. 

The salicylates have the best reputation as affording relief from 
the pain and can be given in any form, perhaps best in the form 
of aspirin, in 1 to 3 grain doses, to a child of two years. Codeine 
can be used to advantage. 

Quinin to older children can be combined with the aspirin in 



410 THE DISEASES OF CHILDREN. 

capsule or yerba santa as a vehicle. Vigorous stimulation may 
be needed and, of course, when needed it is urgent. 

In no other condition, perhaps, is a tonic treatment so indicated 
as in the convalescence from la grippe, and especially in the 
respiratory and gastrointestinal forms, some preparation of cod 
liver oil is of the greatest benefit. 

Hydrotherapy for the fever in the form of sponge or full 
baths. 

DIPHTHERIA. 

Definition. — This is an acute infectious and transmissible 
disease, characterized by the deposit of a false membrane, caused 
by the action of a specific organism, the Klebs-Loeffler bacillus. 
The pseudomembrane may develop on any mucous surface or on 
a denuded area on the skin. It is primarily a local disease, and 
the severe general symptoms and the complications are due to 
the toxins formed by the bacilli. 

Etiology. — Diphtheria is caused by the Klebs-Loeffler bacillus. 
In the majority of cases the source of the infection cannot be 
traced. It may be endemic or epidemic. Milk, contaminated 
food, toys, cats, feeding utensils, books, clothing, linen, etc., may 
carry the bacillus. No race or people is more prone to develop 
diphtheria than another. Infants under six months are rarely 
affected and adults are much less susceptible. It is most frequent 
between one and ten years of age, perhaps the most cases during 
this period occurring between three and five years. 

The most potent predisposing cause is the condition of the 
nose and throat, accompanying adenoids, chronically enlarged 
tonsils and chronic nasal catarrh. Any condition of the gen- 
eral system which lowers the resistance will act as a predis- 
posing cause, as la grippe, bronchitis or other pulmonary 
diseases. 

Bacteriology. — No attempt will be made to give an exhaustive 
description of the Klebs-Loeffler bacillus, the reader being re- 
ferred to special works on bacteriology for that. It is of interest 
to note that it was not until 1883 that Klebs first described a 
bacillus constantly found in throats of patients dying of diph- 
theria, and a year later when Loeffler obtained the bacillus in 
pure culture and gave his knowledge to the world. 



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CONTAGIOUS DISEASES. 411 

The bacillus is aerobic, but grown also without oxygen, and 
grows best on serum media. It is rod shaped, straight or 
slightly curved. Usually with clubbed ends, varying greatly in 
its measurements. It stains with ordinary aniline dyes, the most 
satisfactory perhaps being Loeffler's methylene-blue stain. 

In bright sunlight the bacillus will not long survive, but it 
does live for a long time in the dark, in the mouth, and on toys, 
etc. Disinfectants have a very speedy effect. It is killed at (70° 
C, 136° F.) with five minutes' exposure. 

When other bacilli are present in diphtheria it is called a 
tnixed infection. The most frequently associated forms of bac- 
teria found are the streptococcus, staphylococcus and pneumococ- 
cus. It has been shown that the primary invasion is not infre- 
quently with the streptococcus, the diphtheria bacillus being en- 
grafted upon the soil prepared for it. 

The streptococcus is most frequently the cause of some of the 
complications met with in diphtheria, chief of which is broncho- 
pneumonia. 

The Membrane. — Membrane may appear upon the mucous 
membranes of the nose and throat due to other organisms than 
the Klebs-Loeffler bacillus. The characteristic diphtheria exu- 
date is of a grayish-white color, and is firmly attached to the 
underlying mucous membrane. AYhen it is removed it leaves 
a bleeding area beneath. There is a swelling of the membrane 
surrounding due to an edema. 

The development of an exudate on the tonsil alone may be a 
simple follicular tonsillitis, and when no histor^^ of exposure is 
given it may be difficult to make a positive diagnosis, but the 
appearance of a membrane upon the mucous membrane of the 
nose, nasopharynx or uvula, is very suspicious of a true diph- 
theria. 

Cultures from this membrane will clear up a diagnosis, and 
this may often be necessary. 

Bacteriological Diagnosis. — Sterile blood serum is best used 
for the first growth. A culture is obtained from the throat by a 
probe, the end of which is wound with sterile absorbent cotton. 
This is rubbed over the membrane, being careful not to touch 
any other part of the throat or tongue. The child is held with 



412 THE DISEASES OF CHILDREN. 

face in good light, and tongue held down with depressor. The 
inoculated swab is then rubbed over the surface of the blood 
serum of the culture tube, without breaking the surface. 

The tube is incubated at a temperature of 37° C. for 12 hours; 
experts can differentiate at the end of five hours. With a plat- 
inum needle a number of the colonies are scraped off the culture 
medium, some of this is washed off on to a cover glass with a 
drop of water. The cover glass is air-dried, passed three times 
through a flame, stained with an alkaline methylene-blue solu- 
tion (Loeffler's) for 10 minutes, cold. It is then rinsed, dried 
and mounted in balsam. It is examined with a 1/12 oil-immer- 
sion lens. The diphtheria bacilli may be found in great num- 
bers, or a few with a preponderance of streptococci in chains. 

Direct examination of the exudate is uncertain and unsat- 
isfactory. 

Virulent bacilli have been found in healthy throats, and nu- 
merous observations have been made which show they persist 
in throats for a long period of time after the disappearance of 
the exudate. Park ^ reports one case in which they were founds 
eight months after the disappearance of the membrane. A pseu- 
dobacillus less virulent is sometimes found in the throat, but it 
is believed these have been derived from the virulent form. 

The bacilli generate a poison or toxin, and this can be obtained 
from cultures of living bacilli, by filtration through porcelain. 

An artificial immunity can be produced in the economy by 
the introduction of an antitoxin, a substance which will act as 
an antidote to the toxin. Natural immunity more or less active 
may exist in the human being. The blood serum of a person 
convalescent from diphtheria contains this antitoxin, but it dis- 
appears after a few weeks. 

Diphtheria antitoxin ^ is obtained by first growing a virulent 
culture of bacilli, sterilizing them by adding carbolic acid solu- 
tion. The solution is siphoned off, leaving the bacilli at the 
bottom. If 0.005 cc, when injected into a guinea-pig, will kill 
it promptly it is of the correct strength ; 250 grains weight of 
this solution, or enough to kill 5000 guinea-pigs, is injected into 
a horse, and this is repeated every three to five days, or until 



^Park: Pathogenic Bacteria and Protozoa. ^Park: loc. cit. 



COXTAGIOUS' DISEASES. 413 

the fever reaction has subsided. This is kept up until at the end 
of 20 months 10 to 20 times the amount originally given is used. 
At the end of six months the horse is bled from the jugular 
vein, and from the serum of this blood the antitoxin is obtained. 

The antitoxin is standardized by inoculating a guinea-pig 
weighing 250 grams with 100 or with 10 fatal doses of standard- 
ized toxin, with which has been incorporated an amount of anti- 
toxin believed to be sufficient to protect from the toxin. If the 
guinea-pig lives for four days, but dies soon after, the amount 
of antitoxin added to the toxin was just one unit. 

Pathology. — A study of the exudate or pseudomembrane is 
the chief consideration in this section, though the pathological 
changes occurring as complications must be considered. 

The pseudomembrane may be situated on any mucous mem- 
brane of the body or upon the skin upon which there is an ab- 
rasion. In the order of frequency of involvement might be men- 
tioned the tonsils, uvula, nasopharynx, nose, conjunctiva, larynx, 
trachea, and vagina. 

The exudate is grayish-white in color, and dips down into the 
mucous membrane beneath, being intimately attached, and leaves 
a bleeding surface when pulled off. It is composed mostly of 
fibrin, leucocytes and diphtheria bacilli in pure culture or mixed 
with the other organisms previously mentioned. 

The nerves are specially acted upon by the toxins, the periph- 
eral nerves being the ones chiefly affected. This degenera- 
tion may be parenchymatous, interstitial or fatty. The cord 
and brain may undergo degeneration also. The muscles may 
show a degenerative change without nerve involvement. One 
of the principal muscles involved is that of the heart, fatty infil- 
tration and degeneration being the chief change. 

Bronchopneumonia is frequent, but chiefly due to the asso- 
ciated bacilli, streptococcus, staphylococcus and pneumococcus. 

The lymphatic glands, especially about the neck, are enlarged 
due to cell inflltration with occasional hemorrhages. 

The kidneys may show involvement also from the toxins, 
similar to the degeneration accompanying the other acute infec- 
tious diseases. The parenchyma and glomeruli are principally 
involved. 



414 



THE DISEASES OF CHILDREN. 



Symptoms. — The clinical classification, according to the loca- 
tion of the membrane, we consider the best. If a bacteriologic 
examination is made it may be further classified according to 
these findings, a pure culture of the diphtheria bacillus or a 
mixed infection, in which other bacteria are found in addition 



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Fig. 75. — Laryngeal and nasal diphtheria; intubation. 



to the Klebs-Loeffler bacillus. These are chiefly the streptococcus, 
staphylococcus and pneumococcus. 

The onset is usually gradual; the child may complain of gen- 
eral malaise, beginning frequently with vomiting. The fever 
does not run a characteristic curve, its height and course de- 
pending upon the amount of toxemia, the amount of the individ- 
ual resistance or immunity, and the amount of mixed infection. 
In mixed infection it is apt to run much higher than in pure 
culture form. It is present to some extent in all cases averaging 
from 101° F. to 102° F. 

The pulse rate is always increased, depending upon the amount 
of toxemia, and not in proportion to the height of the tempera- 



CONTAGIOUS DISEASES. 415 

ture. A very rapid pulse is not a good sign. The younger the 
patient the more rapid the pulse. 

The child may or may not complain of its throat, may only 
have pain on swallowing, or severe dysphagia may be present. 
The degrees of this symptom depends entirely upon the amount 
of infiltration in the tissues of the throat. 

The tonsils and uvula may be covered with a thick exudate 
and the child not complain of its throat, especially if it has been 
hurt previously in an examination of the throat, and if but a 
little sore, fears another examination. Hence, the importance 
and the absolute necessity of examining the throat in every sick 
child as a matter of routine. 

The membrane described above is found on one or both tonsils 
or the uvula in addition. The glands are enlarged about the 
angle of the jaw and at the back of the neck. 

The child refuses nourishment or takes very little at a time. 
The urine is high colored and much more scanty than normal. 
According to the amount of toxemia will albumin and casts be 
found. The urine should be regularly examined for albumin, 
and when present a microscopic examination made also, though 
a microscopic examination should be made as a routine measure. 

Generally a leucocytosis is present, its amount depending upon 
the membranous involvement. The hemoglobin and red blood 
cells are relatively decreased. 

If there is nasal involvement there will be a discharge from 
the nostrils, which is apt to be blood tinged, and an excoriation 
of the skin of the upper lip occurs. There is obstruction to 
the breathing through the nose and in the breast or bottle fed, 
nursing is interfered with. The nasal variety occurs infre- 
quently in the very young, and it may be seen as a primary 
lesion, though it usually occurs as a complication of the faucial 
form. 

My experience has been that in primary nasal diphtheria the 
symptoms are as a rule more severe than in the uncomplicated 
faucial variety, though there are cases in . which the diagnosis 
may not be made. Where the diagnosis is not made, and the 
case looked upon as one of a severe ''cold," it is a great menace 
as a distributor of the infecting organism. If both fauces and 



416 THE DISEASES OF CHILDREN. 

nares are covered with membrane the toxemia is apt to be very 
severe. 

If the membrane occurs in the larynx, as a primary condition, 
there are apt to be three stages, the stage of invasion, in which 
the child is listless, has some fever, perhaps a slightly croupy 
cough, and lasts from a few hours to 24 ; the spasmodic stage, in 




Fig. 76. A. Diphtheritic casts of trachea and bronchi. B. Diphtheritic cast of nose. 
(Case of Dr. Lee Kahn.) 

which the membrane has formed. In this the croupy symptoms 
are exaggerated, the cough more spasmodic, there is very decided 
stridor, with recession of the suprasternal and supraclavicular 
spaces. As a late phenomenon, before the third stage or stage 
of asphyxia occurs, the intercostal spaces and epigastric region 
recede with each inspiration. In the stage of asphyxia all the 
extraordinary muscles of respiration are brought into play. 

From the beginning of the second stage, when obstruction 
has begun from the membrane forming, the child is restless, sleeps 
fitfully, and the depression is very profound. The pulse is ac- 
celerated out of ratio to the respiration. 



CONTAGIOUS DISEASES. 417 

As obstruction advances there is cyanosis, blueness of the lips 
and about the nose, finger and toe nails, clammy skin, cold ex- 
tremities, and unless relieved death quickly ensues. 

The enlargement of the lymph nodes of the neck, and at the 
angle of the jaw is quite marked in all of these forms. 

Complications and Sequelae. — The Kidneys. — Albuminuria oc- 
curs in about 60 per cent of cases, and in a smaller percentage 
there are evidences of a parenchAmiatous degeneration, hyaline 
and granular casts, with occasionally blood casts. 

Lungs. — In the mixed-infection cases bronchopneumonia is 
a frequent complication. The consolidation is usually along the 
posterior borders of the lungs, patchy in its extent. This com- 
plication is less often seen in pure-culture forms of diphtheria. 

The first evidence of a complicating pneumonia is a sudden 
increase in the number of respirations with dilatation of the alte 
nasi and a rise in the temperature. 

Bronchitis is frequently seen evidenced by an increase in the 
cough, respirations more rapid and slight rise in temperature. 

Xervoiis Si/stem-. — Perhaps the most important changes occur 
in the nervous system as a result of the toxemia. These compli- 
cations were more often encountered before the antitoxin was dis- 
covered. 

The changes are 'those of a fatty degeneration, usually, and 
it evidences itself by paralyses of various muscles. It most 
often begins during the stage of convalescence, perhaps several 
days after the case has been dismissed, though it may occur 
early. The group of muscles most frequently involved is of the 
throat, chiefly of the palate, and will not be noted until there is 
a regurgitation of liquids through the nose as the child swal- 
lows; attempts at swallowing may be followed by spasmodic 
coughing from the liquid falling into the glottis. In this form 
of paralysis the muscles usually recover their tone in three or 
four weeks. 

Auy muscle or group of muscles may be involved, the eye. legs 
or arms. Cases of sudden death are most often due to a paralysis 
of the heart. 

Diagnosis. — Considerable doubt may exist in one's mind as 
to the true condition existing in a case of membranous deposit 



418 THE DISEASES OP CHILDREN. 

on the mucous membrane of the throat or nose, which can only 
be decided by a bacteriologic examination. 

However in a case presenting a dirty-white membrane in the 
throat or nose which is not easily removed, a slight rise of tem- 
perature, enlargement of the lymph nodes, with evident prostra- 
tion, as the element of time plays so important a role in treat- 
ment, it is safe to administer the antitoxin at once and confirm 
the diagnosis by bacteriologic examination later. 

Follicular tonsillitis is more often mistaken for diphtheria. 
In this the tonsils are enlarged, but the edema of surrounding 
tissue is not so great, and if seen early the follicles containing 
the whitish deposit are discrete. It is later, when these coalesce 
over the surface of the tonsil, that the diagnosis is doubtful, but 
there is no tendency for the membrane to spread. When coal- 
esced it can be more easily mopped off. The constitutional 
symptoms are more severe and the onset more sudden. The 
temperature is higher also. General aching is present as a rule 
even in young children, and they complain when handled. How- 
ever, even though the diagnosis seems clear, especially when other 
children are in the house, a bacteriologic diagnosis should be 
made. 

Quinsy. — A peritonsillar abscess may be confounded with 
diphtheria. In a case under my observation recently the con- 
sultant laryngologist believed the condition a diphtheria, but at 
my request endeavored to find pus by an incision, without suc- 
cess. Twenty-four hours later spontaneous rupture of the ab- 
scess occurred below the incision, which confirmed my diagnosis 
and cleared up all symptoms. There is very often an exudate 
over the affected tonsil and mucous membrane adjacent which 
can be removed without difficulty. 

If but one side is affected the swelling is chiefly of that side, 
and the edema of surrounding tissue quite severe. The patient 
talks as if the mouth was full of mush. 

Group. — This form of trouble maj^ be either catarrhal, false 
croup, or diphtheritic, true croup, and without visible membrane 
in the throat the diagnosis may be difficult. Direct inspection 
of the epiglottis is possible in the very young, but not in the 



CONTAGIOUS DISEASES. 419 

older children, and inspection by means of the laryngeal mirror 
is impossible in the child. 

In catarrhal croup the child is a^Yakened by a harsh, brassy, 
spasmodic, cronpy cough, having been put to bed usually with- 
out anything having been noticed unusual in its condition. It 
may have had a slight evidence of "cold" in the head for a day 
or so previously. There may be some stridor, with evidence of 
obstruction to inspiration, but without recession, and but a 
slight rise of temperature. By morning, as a rule, it is com- 
fortable, and but little cough is noticed, but when it does cough 
it is of the same brassy, harsh character. These symptoms have 
a tendency to recur for one or two nights subsequently. A few- 
doses of ipecac, 20 or 30 drops of the syrup, or antimony and 
ipecac tablets (1/100 grain each), repeated at one- or two-hour 
intervals, a cold, wet compress to the throat and a steam-laden 
atmosphere for it to breathe, usually give relief in this form. 
It would be best to apply the term "croup" to the catarrhal form 
only. 

After tonsillectom}^ the abraided surface is covered with a 
necrotic looking membrane, which resembles the diphtheritic 
membrane very much. 

Prognosis. — This depends to a very great extent, in this day 
of antitoxin, to the promptness with which the diagnosis is made 
and the first injection of antitoxin given. 

It depends greatly also upon the age of the patient. The 
younger the child the graver the prognosis. The site of the 
lesion also influences the prognosis. In purely tonsillar or phar- 
yngeal cases the outlook is better, the nasal form less so, 
and the laryngeal cases very bad. The mortality in the laryngeal 
cases requiring intubation, even with the antitoxin, is very high. 

Treatment. — In no disease has the mortality been so influenced 
as it has in diphtheria by the use of the diphtheria antitoxin. 
Statistics show the mortality has been reduced 50 per cent since 
the antitoxin era began. 

Prophylaxis. — This is most important and is best accomplished 
by the medical inspection of schools; removal of diseased and 
enlarged tonsils and adenoids, strict quarantine of affected cliil- 



420 THE DISEASES OF CHILDREN. 

clren; careful disinfection of all bedding, clothes, feeding uten- 
sils and rooms vacated by those who have been affected ; bacterio- 
logical examination of the throat before the child is dismissed, 
with a general bath after leaving the room ; extreme care on the 
part of physician and nurse when entering and leaving the 
sick room, and the immunization of the children in the family 
or ward exposed to it. 

Immunizing doses of antitoxin are usually advised as fol- 
lows : for infants 300 units, 500 units for children up to 15 years, 
and 1000 units for adults. The immunity from this dosage lasts 
from two to four weeks. This dosage should be repeated if it is 
desired to prolong the immunity. Since the introduction of the 
concentrated form of antitoxin the complications formerly seen 
are less frequent, viz., the rash and severe urticaria. 

After the child has recovered, the woodwork of the room 
should be first wiped down with a solution of 1 :60 carbolic acid, 
and then disinfected with formaldehyd or formaldehyd and sul- 
, phur, or permanganate of potash. 

Curative Treatment. — As soon as the diagnosis has been posi- 
tively made, a curative dose of diphtheria antitoxin should be 
given. To a child of five years an initial dose of not less than 
3000 units should be given. If the toxemia is severe, fever high, 
membranous exudate extensive, the dose should be 5000 units. 
Where no improvement follows within 8 to 12 hours a second 
injection should be made. In laryngeal cases the initial dose 
should not be less than 10,000 units. 

A large number of reliable antitoxins are upon the market 
now and one should be chosen which is furnished in a sterilized 
syringe with sterilized needle and attachments. 

The concentrated serums are preferable, as they less fre- 
quentl}^ cause the disagreeable rashes seen when larger volumes 
of blood serum w^ere used. 

The effect of the serum is usually prompt and decided. The 
temperature falls 1° F. or 2° F. within two or three hours, the 
child soon becomes tranquil and falls asleep. The most typical 
effect is that upon the membrane, within 24 hours it begins to 
curl up at the edges, and graduallj^ peels off and becomes de- 



CONTAGIOUS DISEASES. 421 

tachecl either in its entirety or in places. The swelling and 
congestion of the mucous membrane become less marked. 

The serum is best injected in the loose tissue of the back be- 
tween the shoulders or in the loin. The advantage of this is the 
child does not see the preparations for the operation and is easily 
held w^hile it is being done. Careful preparation should be made 
of the skin by soap and water cleansing, followed b}^ alcohol, the 
sterile covering of the needle not being removed until everything 
is ready. The point of injection is covered by an inch-square 
piece of zinc oxide adhesive plaster, or sealed with collodion. 

Complications Following Antitoxin. — More than 19 cases have 
been reported of sudden death following the use of diphtheria 
antitoxin. The cause of these fatalities has not been satisfac- 
torily proven, but it is supposedly in cases of so-called status 
lymphaticus, and death occurs within a few minutes after the 
injection. Some exhibit alarming symptoms, sudden dyspnea, 
fainting, cyanosis and feeble, rapid pulse wdth recovery. These 
are believed to be phenomena due to the horse serum and not to 
the antitoxin it contains, von Pirquet's theory being that they 
are due to the antibodies. 

Skin eruptions before the concentrated serum was used 
occurred quite frequently. These rashes w^ere scarlatinaform 
or urticarial, w^hen of the latter variety accompanied with great 
itching. Occasionally enlargement of the joints occurred. 
There is quite regularly a rise in temperature when these compli- 
cations occur. 

General and Medicinal Treatment. — Concentrated and 
nourishing food should be given, milk, in small quantities, and 
as often as every two hours ; animal broths and beef juice. Gav- 
age and rectal nourishment should be used if necessary. Ene- 
mata for constipation; hydrotherapy for temperature over 102° 
F. ; sponge or tub baths. Stimulation is quite regularly indi- 
cated, and only a good bottled-in-bond whisky or brandy should 
be given. The quantity for 21 hours, half an ounce to an ounce, 
should be diluted with 2 or 8 parts of Avater, and this given at 
frequent intervals as indicated during the day and night. This 
can be supplemented by the hypodermic injection of strychnia 



422 THE DISEASES OF CHILDREN. 

grain 1/200 to grain 1/100 according to the patient's age, or 
strophanthus by the mouth. The bowels should be specially 
watched. 

Bromide and chloral, or Dover's powder, can be given in cases 
of extreme restlessness. Sedatives are usually indicated in the 
tube cases on account of the extreme restlessnsss from asphyxia 
and spasmodic coughing. Tonics following the attack are spe- 
cially indicated. 

Absolute rest in bed in a well ventilated room is the first req- 
uisite. It must be possible to effectually quarantine the sick 
room. 

Local application of cold to the throat is beneficial in form of 
wet cold compresses or an ice bag. 

Local Treatment. — Rarely is it necessary to use any local treat- 
ment in these cases after the injection of the antitoxin. The 
exhaustion following the struggle always accompanying swab- 
bing of the throat is more harmful than if the throat is let alone. 
In the nasal form it may be necessary to irrigate the nose to open 
the nares. This is done by enveloping the child in a towel or 
sheet, holding it on its side on the nurse's lap, protected by a 
rubber sheet, and with fountain syringe containing a warm 
boracic acid solution or normal saline solution, one drachm to 
the pint, held 2 feet above its head, the upper nostril is irrigated, 
the solution returning through the lower one. With head slightly 
lower than the body there is no danger of the fluid being aspi- 
rated in the lungs. 

INTUBATION. 

To the late Dr. Joseph O'Dwyer of New York is due the per- 
fection of the intubation tube for the relief of stenosis of the 
larynx. In 1883, after many months of trial and experimenta- 
tion, Dr. O'Dwyer brought to the notice of the profession gen- 
erally the intubation tube which he had perfected. It is due to 
Dr. O'Dwyer 's memory to state that practically the only im- 
provements that have ever been mad(" in tlie tube were made by 
Dr. O'Dwyer himself before his death, the most perfect ones 
in use to-day being those made according to the 'Dwyer pattern. 
The tubes are made according to scale, usually in five sizes, corre- 



CONTAGIOUS DISEASES. 



423 



sponding to the age of the child. They are made of metal, gold 
plated, and have a central swell which holds them in position, 
and a head and narrow neck which fits in the chink of the glot- 
tis. 

In selecting the tube for the age of the child the scale is con- 
sulted, and the smallest tube which will remain in position is 
chosen. The tube reaches to Avithin a short distance of the bifur- 
cation of the trachea. The rest of the set consists of a mouth 
gag, with which the child's mouth is held open; and introducer. 




Fig. 77. — O'Dwyer Intubation Tubes. 

upon the end of which is screwed the obturator, and an extractor 
or the extubator. In some of the late models of intubation sets 
each of the tubes contain an obturator easily attached to the 
shank of the introducer. Upon the side of the head of the 
tube there is a small opening into which is inserted a piece of 
thread long enough to reach beyond the mouth of the child in 
order to make it easy to remove the tube in case the opening be- 
comes blocked with dislodged membrane, or if it has been pushed 
into the esophagus instead of the larynx. 

Indications for Intubation. — An intubation tube is never intro- 
duced unless positive indications for its use are present. If in 
spite of the use of the diphtheria antitoxin the child has increas- 
ing asphyxia, evidenced by cyanosis and marked retraction of 
the spaces above the sternum and the clavicles, of the intercostal 
spaces and the epigastric region, it is imperative, in order to 
save the child's life, that a tube be inserted. Under these condi- 



424 THE DISEASES OF CHILDREN. 

tions the patient is extremely restless, its respiration is very 
rapid and there is gradual deepening of the color to a deep cy- 
anotic hue. 

Operation. — 'Dwyer originally advocated the introduction of 
the tube with the child in an upright position, but it may be 
conveniently introduced with the child upon its back, with its 
chin slightly raised. The child should be wrapped carefully 
from shoulders beyond its feet in a sheet, thus confining its arms 
and legs. The child is held upon the right side of the lap of the 
nurse, its head resting against her chest, one of her arms en- 
circling the lower part of the chest, the other steadying the head 
with hand upon the forehead. If enough resistance is at hand 
the nurse holding the child uses both arms to hold its body in 
position and the assistant steadies the head and holds the gag 
which has been introduced into the mouth. Many operators 
prefer to introduce the tube with the child lying upon its back, 
wrapped in a sheet as described. 

After selecting the proper tube the thread is placed in posi- 
tion through the hole in the head of the tube and the intubator 
is examined to find if it can slip off the tube from the obturator 
easily. The thread is held firmly in the hand Avhich is to be 
used to introduce the tube, the index finger of the unengaged 
hand is carried into the mouth and the epiglottis located and 
pulled forward, and the tube is then carried with the index finger 
as a guide directly into the larynx. AVith the attachment on the 
intubator the tube is slipped off its obturator and the obturator 
quickly withdrawn, the tube being pushed home by the finger 
still within the mouth. 

As soon as the tube has been pushed home there is an instant 
change in the character of the cough. It now becomes harsh 
and brassy, and a good deal of spasmodic cough is caused. The 
child coughs more than it did before, and occasionally may 
cough up through the tube small pieces of membrane. After 
the first paroxysm of coughing the child usually falls into a sound 
sleep, the cough gradually lessens and the whole picture is 
changed. 

Some advocate the leaving of the thread in the mouth, curling 
it up and placing it at the posterior margin of the tongue between 



CONTAGIOUS DISEASES. 



425 



the cheek and the gum, but this usually proves very unsatis- 
factory. As soon as it is certain that the tube will not be 
coughed up the finger is carried into the mouth after reintro- 




Fig. 78. — Position for intubation. First step. 




Fig. 79. — Intubation. Second step. Introducer about to be removed. 

ducing the gag and with the finger on the tube the thread is cut 
and slowly withdrawn. 

The length of time it will be necessary for the tube to be 
worn varies very greatly. Some cases have been reported in 
which the tube could not be dispensed with before the end of 



426 



THE DISEASES OF CHILDREN. 



three weeks. It is well, as a rule, to allow the tube to remain in 
position for not less than five days, and if at the end of this time 
the fever has subsided and the respirations are normal it may 
be safe to remove the tube, having everything at hand necessary 
for its reintroduction in case a spasmodic condition arises again, 
necessitating its reintroduction. 

Extubation. — After close watching of the patient it is decided 
that the tube can be removed, the child is prepared as for intu- 
bation. The gag is inserted, the index finger carried to the tube 




Fig. 80. — Position for feeding child wearing intubation tube. 

and the extractor with beak closed is carried down to the tube 
along the finger as a guide, placed in the opening, thumb is de- 
pressed, beak opened and by lowering the hand the tube is with- 
drawn. 

Feeding. — During the wearing of the tube it is very necessary 
that the child be fed in the recumbent position, with its head well 
over the edge of the bed, or the nurse's lap, and below the level 
of its body. Usually the child is very easily fed in this position, 
and will either take its milk or food from a spoon or a bottle. 
This position was first suggested by Dr. Cassellberry of Chicago, 
and has been of very great service. Only liquids should be given 
until the tube is removed. 

This operation has practically entirely superseded the old 
operation of tracheotomy, which is the making of an opening 
in the trachea immediately below the cricoid cartilage. 



CONTAGIOUS DISEASES. 427 

INCUBATION AND QUARANTINE IN CONTAGIOUS 
DISEASES. 

The following is the report of the Committee on Quarantine 
of the Medical Society of the Connty of Dutchess (New York), 
embracing suggestions regarding periods of incubation and 
quarantine in contagious diseases, and are reproduced because 
of their conciseness : 

Small-pox. 

Small-pox is considered the most infectious of all diseases. 
Period of incubation 1 to 10 days in the great majority of 
cases; shortest time 5^ days, longest time 16 days. 

Prophylaxis. — Vaccination, revaccination and isolation. Vac- 
cination may render one immune to the disease up to the fourth 
day after exposure. 

Quarantine should continue until all the affected epidermis is 
removed — the dried discs and scales containing infectious mate- 
rial. Each case is one unto itself, and no definite time other than 
stated can be given. 

Diphtheria. 

Period of incubation, 24 hours to 7 days. 

Prophylaxis. — Isolation, disinfection, antidiphtheritic inocu- 
lation. Plenty of fresh air. 

Quarantine should continue until at least two cultures from 
the throat prove negative to the diphtheritic bacillus by bacterio- 
logical examination. 

Measles. 

The second most infectious disease with which we have to 
deal. Period of incubation, 9 to 11 days. 

Prophylaxis. — Isolation during whole course of the disease. 

The disease may be transmitted from the first symptoms until 
after the desquamation, but as the eruption begins to fade the 
danger of transmission diminishes, and during the period of 
desquamation the probability of transmission is but slight. This 
point, however, is a mooted one. The rule is isolation until 
the skin is perfectly clear and normal, and there are no nasal 
or aural discharges. 



428 THE DISEASES OF CHILDREN. 

Scarlet Fever. 

Scarlet fever is considered the third most infectious disease. 

Incubation. — As short as 24 hours ; as long as 21 days ; aver- 
age, 7 to 12 days. 

Prophylaxis. — Isolation for a long time, at least until des- 
quamation has entirely disappeared and the skin is in its normal 
healthy state, and there are no nasal or aural discharges. Proper 
disinfection and hygienic conditions must exist during whole 
course of the disease. Desquamation in this disease is infectious 
as well as the discharges. Serum therapy has not been of any 
avail in this disease. 

German Measles. 

Period of incubation from one to four Aveeks, average time 
14 to 21 days. 

May be transmitted by contact and by fomites. Contagion 
seems to differ in different epidemics. The best authorities state 
that the contagiousness disappears with the eruptions, there- 
fore isolation should be enforced until the eruption has entirely 
disappeared. 

Whooping-Cough. 
. Transmitted by direct contact. 

Infection begins with the earliest symptoms. 

Period of incubation from one to two weeks. 

Prophylaxis.— Isolation until at least the ''whoop" has dis- 
appeared. 

Cerebrospinal Meningitis. 

Transmitted or communicated through secretions of the mouth, 
nose and conjunctiva, but it has not been determined whether 
the disease is communicated to human beings by insects. 

Period of incubation from a few daj^s to three weeks. 

Prophylaxis. — Isolation, disinfection. Isolation should con- 
tinue until the mucous membranes are free from meningo- 
coccus or the diplococcus (meningitiditis) intracellularis. 
Serum therapy has been used successfully in some cases, 

Chicken-Pox. 

Period of incubation four days to a week. 
Prophylaxis. — The person infected should be isolated during 
the entire eruption period and until the removal of the scabs. 



CONTAGIOUS DISEASES. 429 

It must be considered as among the most contagious diseases, 
but the mode of infection is not given. 

Mumps. 

Period of incubation 4 days to 24, average two weeks. 

Prophylaxis. — The disease is transmitted eyen before the 
symptoms appear, and even as long as six weeks after the sj^mp- 
toms have disappeared. 

DISINFECTION. 

In all cases of infectious or contagious diseases, all utensils, 
bedding, toweling and clothing of every kind should be thor- 
oughly disinfected and fumigated. Utensils, by the use of 
formalin, carbolic acid, creolin or bichloride solutions, care 
being taken that bichloride solutions do not come in contact 
with metal. All de.jecta by the use of formalin, copperas or 
persulphate of iron solutions. Bichlorides are not recommended 
for use in dejecta as an albuminate is formed on the outside, 
and proper sterilization is therefore prevented. All bedding 
should be saturated in a formalin solution or one of bichloride 
solution before being sent to the laundry. Where there are 
proper facilities, all bedding, of w^hatever nature, should be 
thoroughly sterilized by superheated steam or by dry heat, espe- 
cialh^ this should be done Avith all mattresses. In institutions 
where this cannot be done the mattresses and all bedding should 
be destroyed. The same should hold for private practice, but 
inasmuch as this procedure in private practice would work a 
hardship to a great many poor people the physician will be able, 
by thorough formalin disinfection and fumigation, to prevent 
the spread of the disease. The bedding, however, should be 
thorough^ saturated in a solution of formalin sufficiently strong 
to be effective. The Avind will clear out the fumes. 

More care in the isolation and quarantine for measles, scarlet 
fever and whooping-cough should be exercised, because there is 
no known medical treatment to cut short the course of, or to 
render people immune to these diseases. With diphtheria and 
small-pox the old pest-house idea should be abolished, inasmuch 
as every one coming in contact with these two diseases may be 
rendered immune by the proper use of vaccine virus and serum 
therapy; the same is probably true of cerebrospinal meningitis. 



CHAPTER XVII. 

DISEASES OF THE CIRCULATORY SYSTEM. 

THE HEART. 

Examination, Defects, Diseases. 

The heart is placed more horizontally in the chest of the 
child, and the apex beat is higher. During the first five or 
six years it is found in the fourth interspace, and slightly to the 
outer side of the mammillary line, and it gradually becomes 
lower as the heart enlarges, until it is found in the fifth inter- 
space. The outline can be made out by percussion with ease, 
because of the thinness of the chest wall, and for this reason 
light percussion is necessary. The relative dulness extends 
from the right border of the sternum to beyond the left mam- 
millary line. 

The pulse rate in the infant and child varies with the age 
and at different times of the day and under varying conditions. 
The following rates may be considered average for various ages: 

Newborn 120 to 160 

First 12 months 100 to 120 

Second year 90 to 100 

Third to fifth year 90 

The blood pressure is not at all constant nor can it be con- 
sidered a very valuable aid in pediatrics. The following rates 
of blood pressure have been given for various ages : 

Infancy 75 to 90 mm 

Children 90 to 100 mm 

Young adults 100 to 135 mm 

An examination of the heart should include careful inspection, 
palpation, percussion and auscultation. Prom inspection we 
learn, in most cases, the location of the apex beat, the presence 

430 



DISEASES OF THE CIRCULATORY SYSTEM. 431 

or absence of dyspnea, and the character and frequence of the 
breathing; color of the skin and nails; position of the patient; 
shape of the finger tips ; the size of the liver and spleen, and the 
amount of gaseous distention of the abdomen. From percussion 
the relative area of dulness of the heart, size of liver, condition 
of the lungs, back and front. The finger is the best pleximeter 
and the hand and fingers the best percussion hammer. By 
palpation the apex beat can be located and its force determined, 
also the character of the pulse. It can be learned whether 
the pulse in the two wTists beats with the same volume, the 
frequency of the pulse and the character of the pulse wave. 
From auscultation, the character of the sounds of the heart, the 
presence or absence of murmurs or a bruit or friction sounds; 
character of the breathing and of adventitious sounds. 

Defects of the heart are frecpiently found at birth, the con- 
genital heart lesions, which may either be the result of imperfect 
development or the persistence of fetal structures, as a patent 
foramen ovale, or a stenosis of the pulmonary or mitral orifices. 
Stenosis of the pulmonary orifice is usually due to fetal 
endocarditis. 

The heart lesions, as the result of disease, are usually 
endocardial, and caused by the infectious diseases, with their 
organisms and toxins. 

Because of the peculiar susceptibility of the heart muscle and 
its lining membrane to bacterial invasion, and the influence of 
their toxins, the changes incident to these complications in the 
infectious diseases as in typhoid fever, scarlet fever and diph- 
theria are greatly to be feared. 

The chief disease at fault is rheumatism, and, as mentioned 
in the section on that subject, a rheumatic heart may be present 
with but few or no joint lesions, the heart being practically the 
only manifestation of the disease. 

Scarlatina and diphtheria cause serious heart lesions, mostly, 
due to the effect of the complicating organism, the usual one 
being the streptococcus. Influenza as a cause of acquired heart 
disease is not generally believed, but I have seen it. Among 
the predisposing causes may be mentioned the seasons, violent 
physical exercise, anemia and chorea. 



432 THE DISEASES OF CHILDREN. 

CONGENITAL HEART DISEASE. 

The most frequent form of congenital heart disease is the 
permanent patency of the foramen ovale. Congenital valvular 
lesions are also found, the chief being of the pulmonary orifices, 
as the right side of the fetal heart is more frequently involved 
than the left. The opening into the aorta is rarely affected, 
though it may be. A number of other congenital lesions have 
been found post mortem, among them being, impervious or con- 
tracted auriculo-ventricular orifices ; impervious or absent aorta; 
continuance of ductus arteriosus after birth ; transposition of 
aorta and vena cava. 

Symptoms. — The chief symptoms of the congenital form of 
heart disease is the early cyanosis and the heart murmur. 

The cyanosis is quite marked, especially when the child cries, 
the skin and nails and mucous membranes are blue, and the 
name applied to these blue babies is morbus ceruleus. 

Bronchitis and bronchopneumonia are not at all infrequent 
in these cases from passive congestion, and principally involve 
the posterior border of the lungs. Clubbed fingers and toes are 
often seen. These children are backward mentally and 
physically. 

Dyspnea and orthopnea are frecjuent, and the pulse is much 
increased in frequency. With rupture of compensation edema 
of the lower extremities takes place. 

Diagnosis. — The diagnosis of pulmonary stenosis is made 
principally from the physical signs. The presence of a heart 
murmur and enlargement of the heart can be easily made. 

The murmur is systolic in character and as a rule harsh and 
loud, and heard distinctly over considerable area. The exception 
may be true, a soft-blowing murmur may be heard. It is heard 
usually best at the base and transmitted upward. No murmur 
may be heard. 

Auscultation may prove very unsatisfactory in regard to a 
correct diagnosis of the seat of the lesion. I recall one case in 
which a number of examinations were made by experienced 
diagnosticians, and numerous opinions given, and none was 
correct, as shown by the autopsy findings. 



DISEASES OF THE CIRCULATORY SYSTEM. 433 

A systolic murmur in the center of the precordial area not 
transmitted is suggestive of a patent foramen. 

Prognosis. — This is always grave, since children with con- 
genital heart lesions, the blue babies, rarely survive the second 
year. They may be well developed at birth, but soon become 
anemic, athreptic and emaciated. As a rule they do not reach 
puberty. Stoelker gives 193 cases, 24 died in first six months; 
42 before the end of the first year; 56 before the tenth year, 
and 71 before the twentieth year. 

The degree of cyanosis and dyspnea influence the prognosis. 
If these children can be placed in proper surroundings in regard 
to home life, climate, etc., the prognosis is better. They are 
susceptible to pneumonia, especially due to the passive pulmonary 
congestion. 

Treatment. — The treatment is unsatisfactory as far as cure of 
the condition is concerned. It is largely symptomatic, with a 
general supervision over the diet, exercise, habits and clothing 
of the child. It should have tonics and nourishing food, which 
will not cause an attack of indigestion, and should be guarded 
against the contagion of the exanthemata and pulmonary dis- 
eases. Its clothing should be warm and changed according to 
the seasons, and in winter, if possible, it should be taken to a 
warmer, more equable climate, where an out-of-door life in 
the sun can be led. The exercise must never be violent, but 
under supervision. If digitalis is given as a heart tonic it should 
be in small doses, and increased in the presence of ruptured 
compensation. Strychnia or strophanthus are valuable adju- 
vants in an emergency. Oxygen for extreme cyanosis is of 
benefit. 

PERICARDITIS. 

Definition. — This is an inflammation of the serous membrane 
enclosing the heart, the pericardial sac. 

Forms. — It occurs as an acute condition, and two forms are 
recognized, the dry pericarditis and pericarditis with effusion. 

Etiology. — Dry, Fibrinous, Plastic. — It is most frequently a 
secondary condition to a general infectious disease. The bac- 
teria localized bv Flexner are chieflv the micrococcus lance- 



434 THE DISEASES OF CHILDREN. 

olatus, streptococcus, staphylococcus aureus, bacillus pyocyaneus, 
influenza bacillus and the tubercle bacillus. Rheumatism has 
long been looked upon as a cause, and it may occur both during 
the attack and a number of days after the subsidence of the 
acute rheumatic symptoms. Babcock mentions nephritis as a 
cause of pericarditis not often thought of. Trauma is also a 
cause. 

Pathology. — The smooth serous membrane is injected, there 
is an endothelial desquamation and the surface is roughened 
from a fibrinous exudate. Serofibrin or serum may be thrown 
off, enough to separate the two layers, but they may adhere and 
form fine fibrous bands or a more dense and firm set of adhesions. 
A myocarditis may also be present. 

Symptoms. — This condition may pass unrecognized unless an 
examination of the heart is made. Suspicion may be aroused 
by the rise of temperature, which follows beginning inflamma- 
tion of the pericardium. 

Pain is rather a constant and prominent symptom w^hen the 
child is old enough to localize it. It may be referred to the 
precordial region, the epigastrium or even between the shoulders. 
As a rule it is not very sharp, but it may be very acute. 

The temperature is quite regularly elevated, to 102° F. or 
perhaps more. The presence of a rise in temperature, in any 
of the exanthemata or rheumatism, should cause the heart to be 
investigated. 

The pulse and respirations are both accelerated. There may 
be some cough, and loss of appetite is usual. 

Physical Signs. — The prominent physical signs are those 
caused by the roughened pericardium, viz., friction fremitus 
and friction sounds. Deep pressure by the palpating fingers 
may decrease the fremitus felt on light palpation. The friction 
sound is usually best heard over the ^middle of the precordium, 
on both systole and diastole. The area of heart dulness is 
increased, quite decidedly so if there is any effusion. The heart 
sounds are apt to be somewhat muffled. 

Occurrence. — Poynton ^ gave some statistics of heart disease 
in children as follows : ' ' Of 150 fatal cases of rheumatism heart 



1 Babcock: Diseases of the Heart. 



DISEASES OF THE CIKCUEATORY SYSTEM. 435 

disease, there was evidence of more or less acute plastic peri- 
carditis in all but nine. In 113 the pericardium was more or 
less adherent, while in 77 the adhesion was complete." 

Diag-nosis. — From endocarditis by the absence of murmurs 
and the presence of friction sounds, pericarditis with effusion, 
the apex beat is displaced or absent. In pleurisy with effusion 
the apex beat may be displaced, but the area of flatness is much 
greater. 

Prognosis. — This is always grave. Occurring as a complica- 
tion of rheumatism or of any of the exanthemata, it is es- 
pecially so. 

Treatment. — This is largely symptomatic, as there is no 
method of aborting the trouble. The heart condition is ben- 
efited by the use of remedies to combat the underlying disease, 
active antirheumatic remedies should be used freely when that 
disease is present. 

Application of an ice bag is of great assistance. A small 
and light one is used, and not completely filled. A piece of 
fiannel is placed between the skin and the ice bag. gradually 
increasing the length of time until it is worn continuously. At 
first it is kept on for a few minutes then removed for a short 
interval. Hot applications can be used but not with the same 
benefit. 

For the pain, discomfort, dyspnea and nervousness opium is 
of benefit. Heroin may also be used. Hydrotherapy may be 
needed for the temperature, if it goes much above IC'2' F. The 
ice bag has a tendency to keep the fever down. 

Digitalis should not be given unless positively indicated, 
rather give strychnia as needed. 

PERICARDITIS WITH EFFUSION. 

The exudate in this form may be serofibrinous, purulent or 
hemorrhagic. Its character cannot be determined unless an 
exploratory puncture is made. 

The pathology of these conditions is largely the same as the 
dry pleurisy, until the eft'usion takes place. 

Symptoms. — The early symptoms before the effusion are those 
of the plastic or dry pleurisy, pain, slight cough, restlessness, 



436 THE DISEASES OF CHILDREN. 

rise of temperature and pulse, etc. As the effusion takes place 
the pain is relieved, and the symptoms then presenting are 
chiefly those of pressure. 

The sac is distended and the area of heart dulness is changed 
in shape, the rounded apex of the triangle being upward. The 
heart is displaced if the quantity of effusion is large, the apex 
beat being found to the outside of the left nipple, as a rule. 

The pulse is usually regular but compressible. It may be 
intermittent. 

Eotch ^ has suggested that a small triangular area of dulness 
is found at the lower right corner, which is easily made out. 

Prognosis. — Depends upon the characters of the fluid which 
is contained in the sac. The hemorrhagic form is usually quite 
rapidly fatal. Owing to the serious myocardial changes which 
may take place the prognosis in children is specially bad. 

Treatment. — Practically nothing can be done to mitigate the 
condition other than has been recommended in the previous 
section. Rest, ice bag, blood letting, etc. The special indica- 
tions are absolute rest in bed, opium for pain and restlessness. 
Salines by the mouth occasionally and aspiration when it is 
indicated. 

Aspiration is done without much discomfort. The needle 
is introduced preferably in the fifth interspace, between the 
nipple line and the sternum border, and between the apex beat, 
if it can be located, and the lower border of the effusion, as 
shown by the flatness, all the fluid which can be removed being 
allowed to escape. If many pressure symptoms are present 
surgical interference is imperative promptly. 

Digitalis is used when indicated only. The fat-free tincture 
in 5 or 10 drop doses is the best preparation, and used for 
its effect. If diuresis is specially desired the infusion of digi- 
talis may be given with decided benefit, a teaspoonful to a 
dessertspoonful every three hours. 

Sleep may be insured by chloretone, in 2 or 4 grain doses. 
Codeine, gr. 14 to i/^, especially indicated if there is any cough 
present; atropia if there is much dyspnea. 



1 Rotch: Pediatrics. 



DISEASES OF THE CIRCULATORY SYSTEM. 437 

CHRONIC PERICARDITIS. 

The process in this variety of pericarditis may be limited to 
the pericardium, or extend through to the tissues of the medias- 
tinum. In the latter form there are usually adhesions, more 
or less dense between the pericardium and the mediastinal 
tissues. 

Pathology. — As a result of the inflammatory process there is 
a new connective tissue growth, if intrapericardial, principally 
between the base of the heart and pericardium. Associated with 
the external pericarditis an inflammation of the adjacent pleura 
may take place, with adhesions between pericardium and pleura. 
Earely an effusion may be present in this form. 

Etiology. — Tuberculosis is usually the cause of the chronic 
form, and it mav follow the recurrence of the acute form. It 
is not very common in children. 

Symptoms. — There may be no special symptoms, save perhaps 
dyspnea on exertion, and when secondary heart changes take 
place, edema, ascites, cough. Physical examination may not 
reveal any distinctive signs whatever in connection with the 
heart, but may reveal the presence of an hepatic engorgement. 
Nothing may be found during life whereby a positive diagnosis 
can be made, but at the postmortem the adhesions are found. 

Treatment. — This is entirely symptomatic. The engorgement 
of the liver must be treated by appropriate remedies. 

PYOPERICARDIUM. 

This is a very rare and fatal condition. 

Etiology. — It is oftenest due to a general pyemia, as may 
occur from otitis media, osteomyelitis, etc. In young children 
it may occur as a complication of pulmonary disease, notably 
empyema, and due directly to the pneumococcus. Sex plays 
no part in its causation. In 100 cases reported by Poynton ^ 
83 per cent occurred before the fourth year, and two-thirds 
between the ages of one and three years. The exanthemata are 
predisposing causes. 

Pathology. — The fluid found in the pericardium varies from 
fibrinopurulent fluid to a creamy pus. The pericardium is 
thickened and adhesions frequent. 



I British Medical Journal, August 15, 1908. 



438 THE DISEASES OF CHILDREN. 

Symptoms. — The beginning of the pericardial infection can- 
not be accurately told, as the friction sounds usually present in 
pericarditis are not nearly as often present as in the other vari- 
eties of pericarditis. 

This form may be acute, lasting several weeks, or chronic, 
running a much longer course. 

The child is ill from the beginning, dyspnea is prominent. 
The temperature is elevated and irregular, the pulse feeble and 
rapid. 

The usual signs are present if the effusion is large in amount. 
Muffling of the heart sounds; increased dulness over the pre- 
cordial region, especially upward toward the left clavicle. 

Prognosis. — These cases are almost universally fatal, and 
many come to autopsy without the diagnosis having been made. 

Treatment. — Supportive treatment and paracentesis of the 
pericardium offers the only hope of cure. The left lower margin 
of the cardiac dulness has been recommended as the point of 
selection. 

ENDOCARDITIS. 

Definition. — An inflammation of the lining membrane of the 
heart, the endocardium, affecting chiefly that portion forming 
the valves. In fetal life it is the right side which is oftenest 
affected. 

Etiology. — The active cause of endocarditis is bacterial, and 
it occurs rarely as a primary affection, more often as a com- 
plication, or as Babcock terms it, a manifestation of rheumatism, 
diphtheria and any of the acute exanthematous and infectious 
diseases. By far the most frequent causes are rheumatism and 
chorea, the following also being causes: tonsillitis, influenza, 
cerebrospinal meningitis, typhoid fever and septic infection. 

Pathology. — The endocardium becomes cloudy, swollen and 
injected, with a chief pathologic process taking place in the 
valves, which are folds of endocardium. At the point of great- 
est strain there may be a break in the surface of the valve, and 
a deposit of fibrin at once takes place, becomes organized and 
forms what are called vegetations. These may be broken off, 
taken up by the circulation and form emboli, causing infection 



DISEASES OF THE CIRCULATORY SYSTEM. 439 

in remote organs. Staphylococci, streptococci and influenza 
bacilli may be found. 

Symptoms. — Many cases of endocarditis present so few symp- 
toms that they go unrecognized, and the fact that the inflamma- 
tion has occurred is only determined by a chance physical exam- 
ination of the heart. Realizing the frequency of the occurrence 
of this manifestation, careful and regular and frequent exam- 
inations of the heart should be made during the course of every 
illness in a child especially when due to infectious diseases and 
rheumatism. 

There may be a sharp rise in the temperature which has been 
on the decline, previously, and with it pain in the region of the 
heart and dyspnea or air hunger,^ and palpation. 

Physical Signs. — The pulse shows a tumultuous action, ill sus- 
tained and frequent, and a throbbing of the vessels of the neck. 
The heart sounds are roughened or muffled and there is prac- 
tically always a distinct blowing murmur heard over the pre- 
cordia with the point of intensity varying according to the valve 
involved. The murmur may entirely take the place of one of 
the sounds. 

Prognosis. — The course of a simple or rheumatic endocarditis 
is toward recovery, but with the heart left in a crippled condi- 
tion, a leaky or an obstructing valve. Cases have been reported 
with complete recovery, without a permanent crippling of the 
valves. Compensation may always exist, and the patient suc- 
cumb to any other condition. Poynton points out the frequency 
of an inflammation of the heart muscle in fatal endocarditis. 
If a vegetation is washed off in the blood current and an embolus 
result, the prognosis is influenced according to the location of 
its lodgement. If in the brain, the outcome is serious, if not 
as to life, certainly as far as permanent recovery is concerned. 

Treatment. — ^With the first evidence of chorea or rheumatism, 
the child must be put to bed at once and absolute rest in bed 
maintained throughout the attack. At the first evidence of 
pain in the precordial region an ice bag should be applied, with 
a light piece of flannel between it and the skin. Heat in excep- 
tional cases may be more acceptable. 



^ Babcock. 



440 THE DISEASES OF CHILDREN. 

The treatment is largely symptomatic, pain is controlled by 
opium in some of its forms; bromides for the restlessness, and 
salines and calomel when indicated. 

The remedies which should be avoided are digitalis, aconite, 
veratrum viride and all of the coal-tar products. Digitalis 
increases systole and throws more strain on the valves ; veratrum 
and aconite depress the circulation too much, as do the coal- 
tar products. 

Strychnia is a valuable agent later, after the acute symptoms 
have subsided. 

As a routine the administration of the salicylates is advisable. 
Aspirin is well borne. 

The diet should be the most easily digested, those foods which 
have a tendency to form gas which would cause pressure symp- 
toms should not be given at all. 

MALIGNANT ENDOCARDITIS. 

Synonym. — Acute ulcerative endocarditis. 

Definition. — This condition is an inflammation of the endo- 
cardium and occurs as a manifestation or complication of gen- 
eral septic troubles, and is rather infrequent in children. 

Etiology. — This is essentially a septic condition due to the 
action of the pus-producing organisms in the endocardium, of 
which the most commonly found are streptococci, staphylococci, 
pneumococci and diphtheria bacillus. The process is more apt 
to be engrafted upon an endocardium previously inflamed. 

Pathology. — In children, in whom ulcerative endocarditis is 
comparatively rare, the process is the same as in adults. There 
is an exaggeration of the condition found in simple endocarditis. 
As its name implies, there may be an ulcerative condition affect- 
ing chiefly the valves, and emboli are more apt to occur. These 
emboli are vegetations full of the infecting organisms, and a 
similar process begins wherever they lodge. 

Symptoms. — The symptoms are those of a general septic con- 
dition, and unless a special examination is made of the heart, 
attention at first is not called to this part at all. The patient 
is in a typhoid state. The fever is usually decidedly intermit- 



DISEASES OF THE CIRCULATORY SYSTEM. 441 

tent in character and inclined to be irregular, perhaps preceded 
by a chill, frequently reaching high, 105° F., or over. The skin 
is hot and dry, except during the free sweats, which are apt 
to be a feature; the tongue dry, the bowels loose, loss of appe- 
tite, the pulse weak and often much accelerated. The patient 
looks profoundly impressed by something and the anemia is 
progressive. 

The physical signs may be very indefinite, perhaps a blowing 
murmur, perhaps none. If the patient develops symptoms of 
a septic nature, following on a simple endocarditis, the diag- 
nosis is usually plain. 

Prognosis. — The prognosis is grave, nearly all cases dying 
promptly. 

Treatment. — Beyond removing the cause of the general sep- 
tic condition, if possible, a nutritious diet, judicious stimulation 
and rest, there is little that can be done. The antistreptococcic 
serum might hold out some hope of relief. 

CHRONIC ENDOCARDITIS. 

The form of endocarditis usuallj^ referred in children to 
which the term chronic is applied, is that which follows the 
acute endocarditis. 

Pathology. — The process following an acute endocarditis is 
that of repair, an absorption of the vegetations on the valves 
and the formation of connective tissue. This may result in a 
deformity of the valves preventing their perfect closure, allow- 
ing a backward flow of the blood, a regurgitation or insufficiency, 
or an interference to the free flow of the blood through the 
valve, a stenosis or an obstruction. 

If the heart muscle develops in proportion to the dilatation 
of the heart cavities, resulting from the overwork because of 
the obstruction at the valvular orifice or a damming back of 
the current, a compensation exists. As long as compensatory 
hypertrophy exists practically no symptoms are present, and 
unless the chest is examined it may go unrecognized. 

The symptoms of ruptured compensation are practically the 
same in all the valvular lesions. 



442 THE DISEASES OF CHILDREN. 

MITRAL REGURGITATION. 

In this condition the mitral valves are incompetent to hold 
the blood of the left ventricle from regurgitation into the 
auricle during ventricular systole. 

Pathology. — The cusps may be so stretched as to overlap and 
allow leakage ; one valve may be contracted following the deposit 
of fibrous tissue. The left auricle receives blood from the lungs 
and from the ventricle at systole, consequently it quickly becomes 
dilated, and because of this crowding it is hypertrophied in its 
attempts to empty itself. When this compensation exists no 
trouble results, but when the auricle is overpowered the blood 
dams back upon the lungs and serious symptoms supervene, 
passive congestion in many important organs resulting. This 
condition is a very common one among children. 

Symptoms. — Practically no symptoms exist during the main- 
tenance of compensation. There may be a visible difficulty in 
breathing on violent exertion, such as running or rushing up 
steps, with a coincident increase in the pulse rate. Children, 
however, rarely complain of this, and unless they evidence some 
pallor after taking this undue exercise, it may not be recognized. 
These children may develop colds more readily, and owing to 
the strain upon the right side of the heart on coughing this 
symptom should be closely watched. 

With rupture of compensation and the general passive con- 
gestion there is bronchitis; catarrhal gastritis; enlargement of 
the liver; engorgement of the hemorrhoidal vessels; nephritis; 
cyanosis and dyspnea. Dropsy is one of the last sj^mptoms to 
develop. 

Physical Signs.— InspGctio7i.— With the chest bared the 
apex beat is found displaced downward and to the left, owing 
to the left ventricular hypertrophy. If the right ventricle is 
enlarged, epigastric pulsation may be noted. 

Percussion shows an increased area of heart dulness. 

Auscultation. — There is a systolic murmur, or bruit, loud 
and blowing, and heard most distinctly over the apex beat. 
It is transmitted under the arm and posteriorly to the angle of 
the scapula. It is synchronous with the first sound of the heart, 



DISEASES OP THE CIRCULATORY SYSTEM. 443 

and it may take the place of the first sound entirely. The 
second sound is accentuated. 

Prognosis. — This depends entirely upon the existence of 
compensation. It is always grave when compensation ruptures. 

MITRAL STENOSIS OR OBSTRUCTION. 

This is an interference to the flow of blood from the auricle 
into the ventricle, and is usually due to an endocarditis. 

Pathology. — The obstruction may be caused by a deposit on 
the valve or at the valvular orifice, narrowing the orifice in 
either event. In consequence the auricle is dilated and hyper- 
trophied, and the left ventricle is relatively smaller in size. A 
right ventricular hypertrophy takes place from increased work 
thrown upon it by passive congestion of the lung. This lesion 
is less frequent in children than in adults. 

Symptoms. — There are very few symptoms in the absence of 
ruptured compensation. Dyspnea is present on the slightest 
exertion, digestive disturbances are common, and these children 
are below par physically. There may be pain in the region of 
the heart, cough may be present, edema develops early, conges- 
tion of the Iridneys follows, and then ascites. Cyanosis of the 
skin and nails develops also. 

Physical Signs. — Inspection. — A distinct impulse may be 
seen at the base, with feeble apex beat, which may be but slightly 
displaced outward. Clubbing of the fingers is quite noticeable. 

Palpation. — An important sign is thus elicited, the 
presytolic thrill being felt. This is a distinct thrill, felt in the 
fourth and fifth interspaces, just before the ventricles contract, 
inside the mammary line; a pulsation can also be felt in the 
epigastrium. The pulse is of less volume than normal and 
slowed, and the left radial may be found the weaker. Percussion 
shows an increased area of dulness downward and to the right. 

Auscultation. — There is a presystolic bruit, heard with 
greatest intensity above and to the right of the apex beat, and 
not transmitted. The murmur is much rougher and harsher 
than the regurgitant murmur. The sounds of the heart arQ 
normal, except perhaps an accentuation or the reverse of an in- 
distinctness of the pulmonary second sound. Babcock describes a 



444 THE DISEASES OF CHILDREN. 

' ' doubling of the second sound, limited to the mitral area, or the 
apex. ' ' 

Prognosis. — This is one of the graver of the valvular lesions. 
The child is stunted in its growth, and from five to ten years 
may be the limit of its existence. Pulmonary complications are 
usually the cause of death. 

AORTIC REGURGITATION. 

Synonyms. — Aortic insufficiency, incompetency. 

In this condition the left ventricle can never completely 
empty itself as the aortic valves are incompetent to prevent the 
blood flowing back immediately into the ventricle during 
diastole. 

Pathology. — In children the condition is due to an endo- 
carditis, is inflammatory, and as a result the cusps are con- 
tracted or held down by bands, making perfect closure impos- 
sible. Vegetations may be so placed on the edge of the valves 
as to prevent closure. 

In this condition an enlarged left ventricle is the first change 
noted, and as it enlarges it may cause an incompetency to develop 
in the mitral orifice. Compensatory hypertrophy occurs early, 
and the wall of the ventricle may be very thick, 1 or li/^ inches 
thick. This heart is called the beef heart or cor hovinum. 

Symptoms. — As in the other conditions, as long as compensa- 
tion exists, there may be no special symptoms. Palpitation is 
not infrequent and may be the only symptom. It is to the pulse 
one must look for rupture of compensation. It becomes weaker, 
and the typical Corrigan pulse is felt if the child's hand is 
elevated above its head. The pulsations are not even or regular. 

Physical Signs. — Inspection. — Visible pulsation may be noted 
in the larger arteries of the body, notably the carotids, but this 
is not as frequently seen in children as in adults. The apex 
beat is displaced downward perhaps as much as two spaces, and 
outward. 

Palpation. — The cardiac impulse is quite strong, the heart's 
action being tumultuous. The characteristic Corrigan or water 
hammer pulse is present. In this phenomenon the child's hand 
being held higher than its head, the finger on the radial artery 



DISEASES OF THE CIRCULATORY SYSTE:M. 445 

feels the strong pulsation, and the artery immediately collapses. 
Percussion. — This sho^vs the extent of the enlargement of 
the heart, the area of dnlness extending farther downward and 
to the left than normal. 

AORTIC STENOSIS. 

This lesion is more rare in children than in adults, being 
quite infrequent in adults. 

There is a narrowing or obstruction of the orifice of the aortic 
valve. 

Pathology. — As in the mitral stenosis there may be adhesions 
holding the valves to prevent their closure, and at the same time 
obstructing the flow, and vegetations may narrow the opening. 
Congenital narrowing of the orifice and aorta itself may rarely 
be present. From overwork in forcing blood through a con- 
stricted opening, the left ventricle is enlarged and hypertrophied. 
As a result of beginning rupture of compensation the left 
auricle becomes enlarged from forcing blood into a partly emptied 
ventricle. 

Symptoms. — As a rule more serious symptoms are present in 
this form of valvular lesion than any other, though, as in the 
others, no symptoms may be present. TV^ith beginning rupture 
of compensation the child is anemic, incapable of the least exer- 
tion, either mental or physical, and is dyspneic. 

]\Iitral regurgitation frequently occurs as a complication of 
aortic stenosis. 

Physical Signs. — Inspection. — Displacement of the apex beat 
downward and outward owing to the enlargement of the left 
ventricle. 

Palpation. — A systolic thrill may be felt at the base, along 
the course of the aorta especially. The pulse is weak because 
of the lessened volume of blood filling the artery. The artery 
does not fill with each pulsation. 

Percussion. — This only confirms the enlargement of the left 
ventricle by the area of dulness being displaced downward and 
to the left. 

Auscultation. — Over the aortic, or second right interspace, 
there is a systolic murmur heard with the first sound, and trans- 



446 THE DISEASES OF CHILDREN. 

mitted upward in the great vessels of the neck. It may follow 
the blood stream down the aorta and be heard between the 
scapulae. 

Prognosis. — Depends on the amount of compensation or rup- 
ture of compensation. The prognosis is serious. Death does 
not occur suddenly in this form. 

TRICUSPID REGURGITATION. 

This is the principal right side heart lesion, and is chiefly 
the result of fetal endocarditis. 

Pathology. — The right ventricle and auricle are enlarged and 
the walls of both are thinned. There are usually other valvular 
lesions associated with this form. 

Symptoms. — Cyanosis and swelling of the veins of the face 
and extremities is an early manifestation of this damming back 
of the venous blood current. Tha congestion extends to the 
abdominal viscera, the liver and the hemorrhoidal plexus of 
veins are enlarged. The child is incapable of exertion, and when 
it cries there is an evident cyanosis. Dropsy of the extremities 
may develop. Hydrothorax may occur. 

Physical Signs. — Inspection. — Enlargement of the veins of 
the neck are quite prominent, and in the event of ruptured com- 
pensation jugular pulsation is seen. 

Palpation. — The venous pulse can be felt ; also one in the liver 
if this organ is palpated. 

Percussion. — Increase in area of cardiac dulness to the right 
and even below the ensiform cartilage. 

Auscultation. — A blowing, systolic murmur is heard best over 
the tricuspid interspace, second left. It may also be heard 
loudly at the ensiform cartilage. 

Prognosis. — This is relatively grave, more so if associated 
with lesions at other orifices. 

TRICUSPID STENOSIS. 

This is a very rare and practically unknown condition in 
children. Babcock ^ refers to only 1154 cases which have been 
recorded in medical literature. 



1 Babcock: Diseases of the Heart and Arterial System. 



DISEASES OF THE CIRCULATORY SYSTEM. 447 

Pathology. — The same morbid anatomy exists as in mitral 
stenosis. 

Etiology. — ^A fetal endocarditis in congenital cases and rlien- 
matism in those developing after birth. The most recorded 
cases occur between 20 and 30 years, and more females affected 
than males. 

Symptoms. — The majority of cases evidently go unrecog- 
nized. Visceral engorgement is the principal manifestation. 

Physical Signs. — Palpation shows the pulse weak and vari- 
able. 

Auscidtation. — Like the other physical signs the sounds are 
indefinite. A presystolic murmur may be heard in the tricuspid 
area. 

Combined Valvular Lesions. — Any two or several of the val- 
vular lesions described may be associated in the same individual, 
as mitral stenosis and aortic regurgitation ; a double mitral lesion ; 
mitral and aortic stenosis, etc. 

Prognosis in Valvular Lesions. — As noted, there is usually 
no immediate danger in cases of valvular lesions in children, 
but because of the secondary symptoms produced, these children 
do not do well, do not thrive. Compensation fails sooner or 
later and they rarely live beyond young adult life. 

The Treatment of Valvl^lar Lesions. — The physician should 
have control of the child's habits of life, its diet, exercise, cloth- 
ing and sleep. The amount allowed of each depends largely 
on the presence or absence of compensation. If compensation 
exists the whole effort of treatment is to maintain it. The exer- 
cise must be under supervision. The nurse or companion should 
notice carefully for over-fatigue, symptoms of dyspnea or pallor, 
and stop violent play at once. Mitral stenosis demands more 
care than any of the rest. Young boys should be warned' and, 
is possible, prevented from using tobacco. The clothes should 
be prescribed, not too light, but warm and protective. Bathing 
to obtain an active skin is most important. The diet should be 
so regulated that no residue for fermentation is left in the bowel 
and stomach. Any intercurrent disease must receive careful 
attention, especially epidemic influenza and tonsillitis. 

Too much emphasis cannot be placed upon the importance of 



448 THE DISEASES OF CHILDREN. 

digitalis, both as a poison and a drug of value. Too many 
physicians use this drug as a regular and routine remedy, no 
matter whether the indication is present or not. It is capable 
of doing great injury, and should be used only when a positive 
indication presents. With compensation present, digitalis is 
not indicated. 

Laxatives should be used when indicated and the formation 
of toxines and intestinal gases prevented if possible. 

When rupture of compensation exists, active and judicious 
treatment is indicated. Every condition which interferes with 
proper aeration and nutrition should be removed. If adenoids 
are present they should be removed, if a gastric catarrh is pres- 
ent it should receive attention, diet should be so regulated that 
no fermentation takes place. 

Digitalis, in the presence of ruptured compensation, is of 
^reat value, the fat-free preparation being prepared. Strophan- 
thus may be used instead. Strychnia is of value as a remedy 
and its effect noted carefully. Its cumulative effect has been 
observed with muscular twitchings prominent. 

For pain in the primary or recurrent endocardial inflamma- 
tion, opium in some form is indicated, either as codeine or 
heroin. 

Best is an important aid in the treatment, special symptoms 
are treated as they arise. 

FUNCTIONAL DISORDERS OF THE HEART. 

Neuroses of the heart in an otherwise normal heart are not 
common in young children. The two conditions most often met' 
are bradycardia and tachycardia. 

BRADYCARDIA. 

This is an abnormally slow pulse rate, below 60 pulsations 
per minute. Very rarely the pulse may be found normally much 
slower than 60. Several in the family may have a slow pulse. 

Etiology. — Heredity may be a factor in its causation. It 
has been noticed to occur in masturbation in a child. It may 
occur during the course of or convalescence from the acute infec- 



DISEASES OF THE CIRCULATORY SYSTEM. 449 

tious diseases ; diseases of the gastroenteric tract ; in degen- 
erative or inflammatory conditions of the heart muscle; in 
uremia; and in diseases of the central nervous system. 

Symptoms. — No special symptoms are present except a very 
slow pulse. There may be a disinclination to and perhaps an 
inability for violent play or exercise. 

TACHYCARDIA. 

This is an opposite condition from bradycardia, the heart's 
action being very rapid. 

Symptoms. — Apparently without cause and without warning 
the heart begins to beat very rapidly, tumultuously and irreg- 
ularly. The pulse is accelerated to 110, or not quite so high, 
and may reach 140 or 150. Palpitation may be a feature of 
the case, and oppression of breathing. A diagnosis from Graves' 
disease must be made in all cases. 

Treatment. — Removal of the cause, if possible; control of the 
diet and limitation of foods which ferment; carefully regulated 
exercise and regular bathing. 

If palpitation is a feature, morphine will be of most benefit; 
the bromides may control the attack; nitroglycerine is given in 
certain cases; aromatic spirits of ammonia. If there is pain, an 
ice bag can be applied to the precordial region. 

These children may stand the strain of school rather badly, 
and its effect should be carefully noted by the teacher. 

ACUTE MYOCARDITIS. 

Definition. — This is an inflammation of the heart muscle. 

Etiology. — It may occur independently of endocarditis or 
pericarditis, but secondary to infectious or septic diseases, 
notably diphtheria, the toxins being the active cause. 

Pathology. — The muscle of the thicker ventricular walls is 
chiefly involved, and the process has been described as paren- 
chymatous and interstitial. There is a granular degeneration 
of the muscle fibers which are soft and the muscle itself flabby. 
Pus may be found in the muscle wall in the interstitial form, 
this form occurring as a sequel to pj^emic conditions. 



450 • THE DISEASES OF CHILDREN. 

Symptoms. — Occurring as myocarditis does, as a sequel to 
infectious diseases, diphtheria especially, the symptoms appear 
as convalescence seems established. The most noticeable con- 
dition is a weakening of the heart's action, which may be evi- 
denced by the character of the pulse, pallor, apparent shock 
and inability to exercise in the least. The pulse is accelerated, 
regular as to time, but irregular as to force and volume. Be- 
cause of the feebleness of the heart's action, there is no apparent 
apex beat, and the sounds are indistinct and muffled. Vomiting 
is usually present and in connection with a weak, slow or irreg- 
ular pulse is not a good sign. Pain in the precordial region may 
be present. 

Prognosis. — Sudden death is not uncommon in these cases. 
The child may be playing about, apparently normal, fall and 
expire in a remarkably short time. The pulse returning to nor- 
mal is the best sign of improvement. A very slow pulse is un- 
favorable. 

Treatment. — Prevention, if possible. The earlier diphtheria 
antitoxin is used the less chance there is for a myocarditis devel- 
oping. Absolute rest in bed, with easily digested food. Pain 
is relieved by codeine or morphine, strychnia is a very important 
adjuvant, and tonics during convalescence, cod liver oil and 
iron especially. 



CHAPTER XVIII. 

DISEASES OF THE BLOOD. 

THE BLOOD OF INFANCY AND CHILDHOOD. 

A study of the blood is a most important diagnostic aid in 
many febrile and other conditions in infancy and childhood. 
An examination of the blood is proceeded with as follows: The 
lobe of the ear should be selected for the puncture. It is cleansed 
with a damp sterile or clean cloth and dried. "With a 
triangular-pointed needle, lancet, or large sewing-needle, the 
skin at the lower edge of the lobe is quickly punctured. The 
first few drops of blood are wiped off, and the next can be used 
for diagnostic purposes. If to be examined at once, with a cover- 
slip touch the center of the drop of blood without touching the 
skin and drop the cover-face down on a clean glass slide. 
From the examination of this slip can be learned whether there 
are any plasmodium malaria or the blood parasites; relative 
number of white cells, number and character of the red blood 
cells, and whether there is an increase in the ''blood plates." 

Counting the blood corpuscles is done best by a Thomas Zeiss 
counter. To do this, the blood is drawn in a special pipette, 
diluted and mixed, placed in the chamber of the counting slide 
and the corpuscles counted. If the distribution of the cells seems 
uniform over the ruled disc, the counting is begun. An objec- 
tive Leitz 5 or Zeiss D and a No. 1 or 2 eyepiece are best used. 
When the number of corpuscles in 360 squares has been counted 
the number must be divided by 360, and multiplied by 800,000, 
which gives the number of corpuscles in 1 cubic millimeter. 
These figures and the amount of dilution are marked on the 
pipette. 

The pipette should be cleaned and dried as soon as the count- 
ing has been completed. 

451 



452 



THE DISEASES OF CHILDREN. 



In counting the white cells the ''white counter" is used, and 
a diluting solution which renders the red cells invisible. 

Hemoglohin may be estimated by means of Dare's, Tallquist's, 
Oliver's or Von Fleischl's hemoglobinometer. The Tallquist 




Fig. 81. — Tallquist hemoglobin scale. 




Fig. 82. — Dare's hemoglobinometer. 

scale is used by soaking into standard filter paper a drop of 
blood and comparing it with a water-color scale of 10 tints, and 
is accurate enough for bedside test, an error of not more than 10 
per cent being made. 

Oliver's instrument consists of a series of 12 tinted-glass discs 
arranged in two rows, the color scheme corresponding to hemo- 
globin percentages of from 10 to 120. 

Von Fleischl's instrument, the cell holding the diluted blood, 



DISEASES OF THE BLOOD. 453 

has a moving color scale underneath, with reflected light shining 
through it. The scale is moved back and forth until the color 
of the glass is the same as the blood. The percentage of hem- 
oglobin is given on the scale. 

At birth the hemoglobin percentage is high, usually 100, but 
after a month or so decreases to 60 or 80. 

The color index of a specimen of blood is obtained by dividing 
the per cent of hemoglobin by the per cent of red blood cells. 

Red Blood Corpuscles. — The blood being spread thickly 
shows the red cells in rouleaux, hence thin spreads must be made 
if the cells are to be examined. They are round, biconcave discs, 
varying little in size in health, averaging about 7.5 fi. 

In disease the red cells may be very small, 2 /^ to 4 /x, micro- 
cytes, or they may be very large, 10 /x or even 20 /z, megalooytes, 
when misshapen they are called poikilocytes. 

During fetal life nucleated red cells are found, but they dis- 
appear as the number of red cells decrease and only recur as a 
result of disease. The nucleated red cells are divided into the 
normohlasts, an immature red cell, the nucleus staining very 
dark. It is found in severe anemias, chlorosis, etc. 

The megalohlast is a very large cell (11 to 20 fx) with large 
nucleus, and occurs in certain grave forms of anemia. Its pro- 
toplasm stains irregularly. The microhlasts are much rarer 
than either of the other. 

The number of red blood cells (erythrocytes) is greater during 
the first forty-eight hours after birth, Hayem placing the num- 
ber at 5,900,000, gradually lessening in number to 4,500,000 at 
the end of the first week. 

White Blood Corpuscles. — The following varieties of white 
corpuscles are recognized: 

1. Polymorphonuclear neutrophilic leucocytes or the polynu- 
clear leucocytes. — These cells comprise most of the white blood 
corpuscles, and are those found in pus. They are irregular in 
shape and none are exactly alike, and stain deeply with basic 
dyes. Stained with Wright's stain the nucleus takes on a deep 
blue color, the protoplasm pink. Their size is 13.5 /x. 

2. Lymphocytes. — These are referred to as lymphocytes and 
large mononuclear cells. The lymphocyte varies in size from 



454 THE DISEASES OF CHILDREN. 

size of red cell to larger, and has a nucleus which stains deep 
blue. The larger cells are much larger than the lymphocytes 
and have an oval nucleus. The large cell is 13 in, the small 10 fi. 

3. Eosinophiles. — These cells are polymorphous. The gran- 
ules are 1 /a in diameter. They take the Wright stain, the nu- 
cleus stains lilac, the granules a bright pink, and the protoplasm 
a pale blue. 

4. Mast Cells. — These stain with Wright's stain. They are 
twice the diameter of the red cell. They are 15 /x in size. 

The frequency of the various white cells is given as follows: 

, Adults 2 

Infants ^ Per cent. 

Lympliocytes 40' to 60 20 to 30 

Large mononuclears 4 to 5 

Polynuclears 18 to 40 62 to 70 

Eosinophiles 2 to 4 | to 4 

Mast cells 1/40 to -J 

Myelocyte. — This cell is found normally in the bone marrow, 
and is found in the blood stream only under abnormal condi- 
tions, as in diphtheria. It stains best with Ehrlich's stain. It 
has a large number of granules, and they take the acid dyes. 

They are 15.75 fi in size. 

Degenerated Leucocytes, which are chiefly degenerated 
lymphocytes and large mononuclear lymphocytes. 

Number of Leucocytes. — In the blood in infancy the number 
of leucocytes is greater than in adults. At birth they may 
reach 20,000 to 25,000. In a week or so the number falls to 
9,000 to 15,000, and later in childhood they are still fewer in 
number, 7,000 to 10,000. After the third year they will average 
8,000. 

General Consideration of Blood Changes. — The examination 
of the blood should be considered in the light of a clinical phe- 
nomenon. Stained smears show the relative number of white 
and red corpuscles, and to the trained eye this is often equiv- 
alent to a differential count. The stain also shows the Plas- 
modia malaria, fllaria and other blood parasites, as well as the 
character of the red cells. 



^ Carr : Practice of Pediatrics. - Cabot. 



DISEASES OF THE BLOOD. 455 

There may be a decrease in the number of red blood cells, 
as in the anemias. There is a temporar}^ increase in their num- 
ber in cyanosis. 

Physiolog'icallv there may be an increase in the number of 
the white blood cells. This occurs normally after digestion, 
exercise and cold baths. A transitory increase is termed leuco- 
cytosis. The term relative leucocytosis is used when there is 
an increase in any type of leucocyte, as lymphocytosis, occur- 
ring in congenital syphilis and scorbutus ; eosin-ophilia, occurring 
in lukemia; neutropliilic leucocytosis. 

Leucocytosis, as stated, is the rule in the blood of infants and 
occurs as a result of intestinal disorders, congenital heart dis- 
ease, rachitis, chronic tuberculosis, toxemias, diphtheria, syph- 
ilis, pertussis, pus conditions, etc. 

Leucopenia is used to describe a decrease in the total number 
of leucocytes. It occurs in malaria, measles, influenza, gastro- 
intestinal troubles of inflammatory type. etc. 

ANEMIA. 

It must be borne in mind in the examination of the blood of 
infants, the normal tendency to a lymphocytosis and the lower 
hemoglobin percentage, when compared with adults. 

In anemia there is a deficiency in the red blood corpuscles 
and a decrease in hemoglobin, the coloring matter of the red 
cells. With these changes there may be a decrease in the total 
volume of blood. The anemias are . classified as primary and 
secondary. 

Primary Anemia. — Definition. — By this form is generally 
understood the anemias, the cause of which is unknown, as per- 
nicious anemia-, there being a grave blood condition, enough to 
cause death, yet the underlying cause not known, and chlorosis. 

Secondary Anemia. — Definition.^ — This can be described as 
a symptomatic (Cabot) anemia, the blood changes being due 
to certain conditions Avhich are more or less Avell known, as hcm- 
orrliagc, maUiria, syphilis, tuherculosis, gastrointestinal elisease, 
scorbutus, rachitis, etc. 

In the secondary form of anemia there is a diminution in the 
colorino^ matter, the number of cells remainiuoj near normal. 



456 THE DISEASES OF CHILDREN. 

It presents in the form in which the red cell is deformed, poi- 
Mlocytosis; they may change as regards their staining qualities; 
the formation of nucleated red cells, the normohlasis, megalo- 
Masts and mdcrohlasts. 

PERNICIOUS ANEMIA. 

Synonyms. — Progressive pernicious anemia; anemia infantum. 

Definition. — This is the form of anemia which is generally 
fatal, and presents a definite blood picture without apparent 
cause. It is comparatively rare in infants. 

Etiology. — This is not known, save that the so-called simple 
secondary anemias have been known to develop into the perni- 
cious form. The ankylostoma duodenale has been given as a 
cause in the South. It has been estimated ^ as occurring in 
about 2 per cent of all internal diseases. It occurs slightly 
more often in males and with great rarity under five years of 
age. Eotch did not find a single case in 2000 cases of children's 
disease in the Children's Hospital of Boston. Stengel believes 
the bothriocephalus may produce this form. 

Pathology. — The anemia, pallor and the extravasations of 
blood into and the fatty degeneration of the internal organs is 
noticeable at once. Free iron is found in the internal organs, 
especially the liver. The chief pathologic changes are in the 
heart. The central nervous system and cord show the same 
hemorrhagic condition as the other organs in addition to anemia. 

The hone marrow in this disease differs from the normal in 
that there is a large increase in the megaloblasts. 

The red cells are markedly decreased, averaging from 1,500,- 
000 to 1,000,000. The hemoglobin is usually decreased, but not 
in proportion to the reduction in red cells, but the opposite may 
as frequently be seen, viz., a relatively high hemoglobin, consid- 
ering the diminution in red cells. The amount of blood is usu- 
ally reduced and coagulation in fresh blood is much slower. The 
fresh blood looks pale in color. The number of leucocytes is 
also reduced. The blood does not show the usual rouleaux for- 
mation. The oval-shaped red cells may predominate. 

Symptoms. — The onset of pernicious anemia is insidious. It 

^ Lazarus ; Notlmagle : Diseases of Blood. 



DISEASES OF THE BLOOD. 457 

may at first be diagnosed as a simple anemia with gradually 
increasing debility and lack of energy, with decreased endurance. 
Pallor of the skin followed by a distinct lemon-yellow color, 
develops very soon. Anemia of the mucous membrane follows; 
there is dyspnea, anorexia, perhaps nausea and vomiting, loss of 
flesh and edema. Palpitation is frequent on the least exertion 
or excitement. Small hemorrhages may occur in the conjunctiva 
and the skin. Hemic murmurs are frequent. Frequently dis- 
tinct remissions occur, when there is an apparent improvement 
in all the symptoms. 

. There is an increase in the number of the red cells, approach- 
ing normal, a decrease in the megaloblasts and increase in the 
normoblasts. There is an increase in the leucocytes, mostly 
the polymorphonuclear neutrophiles. 

The digestive symptoms are improved and the palpitation 
lessened or absent entirely. 

These remissions may be permanent, the case progressing to 
complete recovery, when apparently hopeless before, or go on 
to a fatal termination after a very short period of remission. 

The course of the disease is variable, usually under a year. 

Diagnosis. — The general appearance of the patient is always 
suggestive of the form of anemia present. In no other form is 
the pallor or anemia as intense, but without careful and repeated 
blood examination a diagnosis is not justified. The group of 
symptoms enumerated above, with the characteristic blood find- 
ings, makes a diagnosis certain. These important changes are 
a marked decrease in the red cells, to 1,500,000 or below, and 
an increase in their size; diminished number of white cells; 
slight relative decrease in hemoglobin; presence of megaloblasts 
in increased numbers. 

Prognosis is graver, though apparently hopeless cases have 
recovered after a period of remission. If it is a bothriocephalus 
anemia, and the anemia improves, the prognosis is very good. 
The nearer the red cells decrease to 1,000,000 the graver the 
prognosis. 

Treatment. — The removal of the bothriocephalus latus, if it 
or its eggs can be demonstrated, is the first indication. Felix 
mas is perhaps the most efficacious anthelmintic for this worm. 



458 THE DISEASES OF CHILDREN. 

Special attention should be given the stomach and intestine 
by regulating the diet, controlling diarrhea, if present, and the 
administration of remedies to limit the fermentation, bismuth 
and salol are especially efficacious. Constipation, if present, 
can be controlled by enemata. 

Arsenic is the remedy which gives the best results. It should 
be given in small initial doses, gradually increasing until the 
full physiologic effects have been noticed. The dose should then 
be decreased 20 per cent, and its administration continued for 
several v^eeks at that dose. Fowler's solution is the best form 
for administration. 

The employment of direct transfusion of blood offers much, 
and should be used when possible. 

The patient should be given every opportunity to rally as 
regards his surroundings, climate, rest, freedom from work and 
worry, and during a remission extra precautions taken in these 
details. 

CHLOROSIS. 

Definition. — A primary anemia which occurs in girls about 
the age of puberty. There is an anemia, with diminished, 
though not a marked increase in the number of red cells and a 
lowered hemoglobin percentage. 

Etiology. — It can be said practically that chlorosis occurs 
only in girls, and it is most frequent at puberty, from the twelfth 
to the eighteenth year. Often a history of chlorosis in the 
mother, or members of her family, can be brought out, or a 
tuberculosis in the family. A chronic intestinal indigestion 
and putrefaction, causing an autointoxication, may be a cause. 
Bad hygienic surroundings in factories and in crowded dormi- 
tories with insufficient ventilation may be a predisposing cause. 
Constipation, improper food, lack of proper exercise and tight 
lacing and the changes incident to puberty are given as causes. 

Pathology. — The chief changes occurring in the blood are as 
follows : The hemoglohin is reduced to a decided extent, reach- 
ing as low, in some isolated eases, as 20 per cent, the average 
being about 40 per cent; the number of red cells are reduced, 
but not to the same extent as indicated by the reduction of the 
hemoglobin. The average number of red cells is about 4,000,- 



DISEASES OF THE BLOOD. 459 

000. They are pale, not deformed, but apt to be smaller than 
normal. Poikiloeytosis is present in severe cases. 

The white cells may be normal in number. 

The specific gravity of the blood is reduced. 

Symptoms. — The first symptom noted may be a disinclina- 
tion to exercise in a previously active girl, palpitation, short 
quick breathing or dyspnea, on going up the steps, dizziness, fol- 
lowed in a varying time by pallor of the skin and mucous mem- 
branes, the skin having frequently a greenish tinge. 

The changes in menstruation are more or less constant ; in the 
majority of cases it is absent entirely, if present it is very irreg- 
ular as to time and quantity and color of the flow. This irregu- 
larity of menstruation may be the first symptom noted. Pain 
before or early in the stage of flow may develop. Leucorrhea 
is very often present. The appetite is poor and often capricious, 
craving for acids is often a feature. Headaches are common, 
and are often associated with ringing in the ears. The circula- 
tion is poor, hands and feet cold. Blowing systolic murmurs are 
often heard, at various parts of the precordia, and. a venous 
hum, the 'bruit de diahle, develops over the large vessels in the 
neck. 

No great changes are found in the urine. There may be an 
increase with low specific gravity. The spleen may be enlarged, 
but not markedly so. Hysteria, or milder form of irritability, 
may be seen in the specially neurotic girl. The duration is vari- 
able, usually, however, running for several weeks. 

Diagnosis. — The principal diagnostic features are the sex, 
age. anemia and blood findings, viz.. marked diminution in hemo- 
globin, without corresponding diminution in the number of red 
cells, rapid improvement under proper treatment. In making 
a diagnosis tuberculosis will have to be excluded. 

Prognosis. — Influenced greatly by the period of recognition 
• and time of beginning and persistence in treatment. 

Treatment. — All girls at puberty should receive careful at- 
tention. Best at menstrual epochs, and carefully regulated diet 
and exercise is very important. The articles of diet specially 
indicated are the fats, vegetables and fruits. Those vegetables 
containing a large supply of iron are best, as the green vege- 



460 THE DISEASES OP CHILDREN. 

tables, spinach, etc. A change from the city to the country is 
also of great benefit as a prophylactic. 

At the first sign of anemia or the preliminary symptoms of 
chlorosis the girl should be taken from school, or a very care- 
fully graded course outlined in connection with baths, diet, ex- 
ercise and regulation of the bowels. The medicinal treatment 
is largely symptomatic, except the positive indication for the 
administration of iron. 

The bowels must be regulated by mild laxatives, cascara sa- 
grada, aloin, belladonna and strychnia, etc., and other symp- 
toms treated as they arise. 

Iron must be given in some form ; metallic iron ; ferrous and 
ferric salts; albuminates and peptonates; nucleoalbumin prepa- 
rations. 

Diastiron is very assimilable and easily taken care of by most 
children. It can be given in a half to one teaspoonful, initial 
dose, gradually increased to two teaspoonfuls. 

Pil Blaud, 5 grains, is an excellent method of administration 
of iron, beginning with one after each meal, gradually increasing 
during the second week to two after each meal, then decreasing 
to the original dose after a week. The following prescriptions 
are often found of service: 

IJ. Tincture ferri chloridi f.^ss 

Acidi phosphoric! diluti f.5vi 

Spiritus limonis f.3ii 

Syrupi simplicis q.s. ad f.^vi 

M. Sig. Dessertspoonful in water after eating. 

I^ Acidi phosphor, dil. 
Acidi nitro-mur. dil. 
Acidi sulphurici aromat. 
Tr. ferri chloridi aa f.^ss 

M. Sig. Twenty drops in half glass of water. 

Iron should not be continued indefinitely, nor should it be 
given when no improvement in general symptoms or hemo- 
globin has been obtained in a short time, or when it produces 
decidedly bad symptoms with the digestive organs. One remedy 
which can be used to advantage in chlorosis is arsenic. The 
following pill is of service: 



DISEASES OF THE BLOOD. 461 



Siff. 



IJ Ferri reducti 


gr. Ixxv 


Acidi arseniosi 


gr. iii 


Ext. glycyrrhizse 


q. s. 


M. et ft. pil No. C 




One to four pills daily. 


(V. Noorden) 



LYMPHATIC LEUKEMIA. 



Definition. — In this disease the characteristic symptom is a 
great increase in the number of leucocytes, with an increase in 
size of those organs specially associated with blood-making, 
spleen and glands. 

Two forms are recognized, the acute, in which there is a rapid 
and fatal termination in a few weeks, and the chronic, which 
may continue for months. 

The Acute Form. Etiology. — Two types are recognized, the 
myeloid, in which there is great hypertrophy of the spleen and 
bone-marrow changes, and but little lymphatic enlargement, or 
the lymphoid, in which there is generally a hyperplasia of the 
lymph nodes, and in which the blood shows particularly the 
lymphocytes. 

Leukemia may occur at any age. Heredity is a causative 
factor. Among the other predisposing causes may be men- 
tioned intestinal intoxication; poor surroundings and hygiene; 
malaria ; syphilis ; tuberculosis ; influenza and rachitis. 

Pathology. The Myeloid Form. — The essential changes are 
in the blood, bone marrow and spleen. The red cells are slightly 
diminished in number, averaging about 3,500,000. The hemo- 
globin is diminished probably to 50. The red cells show many 
nucleated forms. The typical changes in the blood are in the 
white blood corpuscles. The leucocytes are greatly increased 
in number, varying from 100,000 to 300,000, though there may 
be a far greater increase. 

The myelocytes are greatly increased in number. They may 
comprise more than one-third of the number of cells, and from 
this feature alone the diagnosis can be made. Polj^morphonu- 
clear cells are slightly increased in number, both large and 
small, with nuclei staining differently. Ljanphocytes are 
decreased quite decidedly, but not as much so as the mj^elocyte. 

The glands show^ cell proliferation and enlargement. 



462 . THE DISEASES OP CHILDREN. 

Hemorrhages are of frequent occurrence, both on mucous sur- 
faces and skin, and ulceration takes place in these areas. They 
may occur in the glands also. 

The bone marrow is changed from the normal fat marrow to 
a dark, wine-colored, soft marrow. 

Lymphatic deposit occurs in the spleen, liver, kidneys, esoph- 
agus, stomach and intestine, tonsils and thymus, all of which 
show enlargement or thickening. 

Symptoms. — The course of acute leukemia is short, from a 
few days to several weeks, rarely lasting months. The onset is 
usually insidious, but it may be sudden, or at least few symp- 
toms are present while the preliminary blood changes are occur- 
ring, which the patient will complain of. 

Lassitude, weakness, dizziness, headache, may precede the act- 
ual symptoms. This is followed by pallor of the skin and mu- 
cous membranes, and shortly by enlargement of the lymph 
nodes, spleen and tonsils. The spleen, when enlarged, is pal- 
pable. Hemorrhages occur in the skin, mucous membrane and 
in the eye. The hemorrhages in the skin may be simply petechias 
or large bruise-like areas. These also occur in the mucous 
membrane of the mouth, gums and palate. Nasal hemorrhages 
may occur. Necroses may develop at tSe site of these hemor- 
rhagic areas. Hematemesis and hemorrhage from the bowel- 
may be seen, and these active hemorrhages may cause death. 

Diagnosis. — The blood changes are typical of the disease. 
In no other condition is a lymphocytosis so marked. 

Prognosis. — This is unusually grave. Hemorrhages and sep- 
tic infection at the site of necrosis may hasten^the end. 

Treatment is of little avail and is largely symptomatic. 
Good food, stimulation when indicated, fresh air, the best sur- 
roundings and administration of iron. 

The Chronic Form. — In this class are included those rare 
forms in which the duration is longer than a few weeks. They 
present the same general symptoms and blood findings. 

Etiology. — Nothing definite is known of the etiology of this 
or the myelogenous form of leukemia; of late some interesting 
suggestions have been made that it is probably the result of an 
infection. 



DISEASES OF THE BLOOD. 463 

Pathology.— The chief change is in the lymph nodes. The 
glands of the neck and thorax are principally enlarged. They 
may be soft and tender. The spleen is enlarged, in some cases 
to a considerable size. The bone marrow is reddish in color and 
of jelly-like consistency. The liver is enlarged, as are the ton- 
sils. Tnmors form in the skin, generally quite small and shot- 
like, but they may enlarge to considerable size. 

Symptoms. — The onset is usually gradual. It is often 
chronic in form. The anemia may precede the enlargement of 
the lymph nodes or vice versa. The glands of the neck usually 
show the greatest proliferation and enlargement, wdth smaller 
ones in the axilla and groin. It may be possible to palpate the 
mesenteric glands. The spleen regularly shows an enlargement, 
sometimes to enormous proportions. 

The blood shows a lympliocytosis. Of the increase in leu- 
cocytes, 90 per cent of them will be h^mphocytes. The average 
ratio of white to red cells is about 1 :50. The lymphocytes are 
usually of the small variety, under 10 /x in diameter, in the 
chronic form, and larger in the acute form. The red cells are 
reduced to 3,500,000, or lower, and the w^hite cells, 300,000. 
Eosinophiles or myelocytes are very scanty or absent. Hemo- 
globin is decreased. 

Hemorrhages are infrequent. 

Dyspnea is a frequent and early symptom, which is due 
partly to blood changes, and chiefly to obstruction from enlarged 
lymph nodes. 

Diagnosis. — The presence of the lyynpliocyiosis is the chief 
diagnostic sign. In the presence of anemia, enlargement of 
lymph nodes and spleen, the blood should always be examined. 

Prognosis. — The progress of this disease is toward a fatal 
termination, though it may last for months. 

Treatment. — Practically nothing can be done in this form, 
as in the myeloid form, except to care for the case systematically. 

If symptoms from the glandular enlargement in the neck are 
present, surgery is indicated for relief, if the general condition 
is fairly good. Arsenic is indicated and should be given as early 
as possible. 



464 THE DISEASES OF CHILDREN. 

PSEUDOLEUKEMIA. 

Synonyms. — HodgJdn's disease; lymphoma. 

Definition. — This is a primary disease of the lymph struc- 
tures. There is an enlargement of the lymph glands and spleen, 
much as in lymphatic leukemia, but without the blood changes 
in the latter. 

Pathology. — Early in the disease the blood may be normal, 
but the hemoglobin decreases as it progresses, and there is a de- 
cided anemia. At first there may be no change in the white 
cells, but later there is a marked increase in the white cells, a 
ratio being sometimes seen (in the presence of adenitis) of 1:80 
when compared to the red cells. The increase is chiefly in the 
lymphocytes. 

The red cells are progressively diminished in number. 

Symptoms. — The chief symptoms are those pointing to the 
lymph glands. These may be hard or soft. The spleen is reg- 
ularly found enlarged. The glands of the neck show the great- 
est enlargement. With the progress of the anemia the 
constitutional symptoms develop, weakness, dizziness, fainting, 
palpitation, etc. Skin tumors develop as in lymphatic leuke- 
mia. Its course is slow and death may occur from pressure on 
the vessels of the neck and on the trachea and bronchi. 

Diagnosis. — The enlargement of the lymph nodes, with blood 
changes, showing lymphocytosis, a relative increase of 1 :200 
ratio of white to red. The diagnosis must be made from a 
glandular tuberculosis, in which there will not be any of the 
typical blood changes, and from lymphosarcoma, in which the 
lymph glands show malignant change and the blood changes are 
iiot those of pseudoleukemia. 

Prognosis. — Death is not as prompt as in leukemia, but just 
as certain in time. There is no cure. 

Treatment. — Apparent improvement has been reported from 
the use of arsenic and the iodides. Surgery is not to be rec- 
ommended. In the large growths about the neck, some good may 
be accomplished by the use of the X-ray. 

PSEUDOLEUKEMIA OF INFANTS. 

Synonyms.— Anemia pseucloleukemic infantum {v. Jahsch) ; 
pseudopernicious anemia {Ehrlich). 



DISEASES OF THE BLOOD. 465 

Definition. — This is a grave form of anemia, first described 
by V, Jakseh in 1889. There is a severe anemia, leucocytosis 
and enlargement of the lymph nodes, spleen and tonsils. 

Etiology. — It may occur independently or develop from some 
of the grave anemias. It occurs between the seventh and ninth 
month and the fourth year. Congenital syphilis is a predis- 
posing cause. 

Pathology. — The chief change is an enlargement to consid- 
erable size of the spleen, which can be seen through the abdom- 
inal wall. It is hard to the feel. The liver is slightly but not 
markedly enlarged. The lymph nodes are quite regularly en- 
larged, but not to the size seen in typical pseudoleukeriiia. 

The Mood shows a marked diminution in the hemoglobin, 
often considerably below 50. There is a regular decrease in the 
red blood cells, to 2,000,000 or below. Nucleated red cells are 
found, megaloblasts and normoblasts. 

The white cells are increased, myelocytes are found. They 
stain irregularly. 

Symptoms. — There are no typical symptoms. Those com- 
mon to the other types of anemia are present. There is gener- 
ally a loss of appetite; enlargement of glands and spleen; ema- 
ciation, with a tendency to develop into a chronic condition. 
Syphilis may be suspected instead of the anemia. 

Treatment. — The administration of iron and arsenic and the 
careful regulation of the feeding are the most important indi- 
cations to be met. 

In older children a rich proteid diet is best ; meat, eggs and 
milk ; in the younger a fat increase should be made and continued 
as long as well borne. 

PURPURA. 

Definition. — This is a condition characterized by hemor- 
rhages occurring under the skin and from the mucous mem- 
branes. 

Etiology. — It is divided into two varieties, purpura simplex, 
the bleeding being limited to the skin, and purpura hemor- 
rhagica, where there are also hemorrhages into the internal or- 
gans and from the mucous membranes. 



466 THE DISEASES OF CHILDREN. 

It may be due to septic conditions and the infectious dis- 
eases, as septic endocarditis and the exanthemata; as a result 
of exhausting diseases, as bronchopneumonia, pertussis, typhoid 
fever, ileocolitis, tuberculosis; from the administration of cer- 
tain drugs, as phosphorus, quinin, salicylic acid, arsenic, bella- 
donna, etc. ; or it may occur without any apparent cause. It 
occurs chiefly under 10 years of age. 

Pathology. — No definite pathology is known, except there is 
an endarteritis, without characteristic changes in the blood. 
Hemorrhages occur in the internal organs, chiefly the supra- 
renal capsules. 

Symptoms. — In the ordinary form, purpura simplex, after 
a day or so of indisposition, headache, anorexia, perhaps some 
indigestion, a number of petechial spots appear upon the skin, 
chiefly at first upon the anterior surface of the lower extremi- 
ties and buttocks, and finally generally upon the whole body. 
Later there may be larger areas of extravasation, large, bruise- 
like spots. As the hemorrhage is absorbed it leaves a bluish- 
black discoloration. Not infrequently some fever is seen, to 
100° F., or slightly more. Joint pains may be present in older 
children. 

Purpura hemorrhagica (also called morbus maculosus, AYerl- 
hoff 's disease). 

In this form, besides the skin hemorrhages, petechial and 
ecchymotic, there are hemorrhages into and from the mucous 
membranes, hematemesis and bloody stools, nosebleed (the most 
common) and exophthalmos, caused by orbital hemorrhage. 
The skin hemorrhages are more numerous. Joint pains, due to 
hemorrhages into them, are common. There are some consti- 
tutional sj^mptoms, temperature from 101° F. to 103° F., with 
prostration, dry tongue and mouth, sleeplessness, the patient fall- 
ing into the typhoid state, with coma or delerium. 

Blood which has been swallowed should be differentiated from 
true melena. 

Where the case progresses rapidly and is quickly fatal it is 
referred to as purpura fulminans. 

Henoch's Purpura. — In this form there are three groups of 
symptoms described ; skin presenting petechial and ecchj'motie 



DISEASES OF THE BLOOD. 467 

hemorrhages, besides urticaria, and perhaps edema; swelling 
and pain in one or more joints; and the visceral symptoms, con- 
sisting of colic, diarrhea and vomiting, and occasionally the 
passage of blood both ways. In addition there may be liema- 
turia, as well as an albuminuria. 

The tendency in this form is to be apparently entirely relieved, 
with recurrences over a period lasting perhaps several years. 

Purpura rheumatica (Schonlein) is the occurrence of hem- 
orrhages in the skin in an attack of rheumatism. There are en- 
larged and painful joints, with frequent endocardial involve- 
ment, temperature, albuminuria, erythema nodosum, etc. 

Prognosis depends upon the form of purpura. In the simple 
form it is good, with tendency to relapses; in the hemor^^Jiagic 
form, where the bleeding is not profuse, the child may recover. 
In the fulminans type it is rapidly fatal; in Henoch's purpura 
recoveries are rare, where it has recurred frequently. 

Treatment. — In all varieties the child should be put to bed 
and kept there until all symptoms are relieved. An antiscor- 
butic diet, fruit juices, fresh milk and vegetables should be 
given. Ergot has been tried without success. If the hemor- 
rhage is profuse, subcutaneous injection of gelatine solution 
should be tried. Direct transfusion of blood may offer some 
help. Adrenalin, five minims of a 1 :1000 solution, hypodermat- 
ically can also be used. Iron and tonics are indicated in con- 
valescence. Normal horse serum may be used. 

HEMOPHILIA. 

Definition. — This is a hereditary disease in which there is 
a tendency to severe bleeding from any surface, from a very 
slight abrasion, or into the tissues. One so affected is called a 
''bleeder." 

Etiology. — The hereditary tendency in typical cases is quite 
marked, and may be traced through several generations, with 
one or more of each family similarly affected. Males are oftener 
affected than females, but the transmission of the tendency is 
more often through the female side of the famil}^, though she 
may herself escape it. Even though herself healthy, and mar- 
ried to a healthy man, their male offspring are liable to 
develop it. 



468 THE DISEASES OF CHILDREN. 

Race may play a part. It is frequent in the Jews. It may 
develop in early infancy or be delayed until after the eruption 
of the deciduous teeth. 

Pathology. — This is unknown. There may be an endarteritis 
or a thinning of the vessel walls. The chief change in the blood 
is the lack of coagulability. 

Symptoms. — The condition may go unrecognized until a 
bleeding occurs from an apparently trivial cut or abrasion, 
which assumes an alarming proportion quickly. If an abrasion it 
may be an oozing, which pressure or other hemostatic measures 
ordinarily used does not stop. The bleeding may occur from the 
mucous membranes, especially the nose, following trauma, into 
the skin or joints. A mere scratch, the pulling of a tooth, the 
cutting of a tooth in an infant, may cause severe and dangerous 
bleeding. 

Diagnosis. — This can be made from the amount of hemor- 
rhage which follows a trivial abrasion, cut or trauma, and the 
distinct hereditary history. 

Prognosis. — These children, if the case is a decided one, 
rarely live to puberty; should they pass this period the chance 
of death being caused from hemophilia grows less and less. 
There is no great tendency to increased bleeding in females at 
menstruation or postpartum. 

. Treatment. — Prophylaxis is the . main consideration. Pre- 
vention of cuts and trauma, but if trauma should occur the hem- 
orrhage should be stopped as quickly as possible. Styptics are 
not of very great benefit but should be tried, perchloride of 
iron, tannic acid or adrenalin may be used. Rest in bed should 
be insisted upon. Operations should not be performed, espe- 
cially removal of the tonsils and adenoids. Adrenalin (1:1000, 
5 or 10 min.) ergot, liquor ferri chloridi (20 min.) can be used 
internally. Fuller recommends the use of thyroid extract. 

Normal horse serum should be used before the case is hopeless. 



CHAPTER XIX. 

DISEASES OF THE LYMPHATIC GLANDS. 

The lymph nodes are very prone to develop hyperplastic proc- 
esses during infancy. Any group of glands may enlarge, or 
there may be a general enlargement of all of them. 

THE THYMUS GLAND. 

But little definite is known of the function of this ductless 
gland. It is C[uite regularly enlarged in the infant, and to it 
have been ascribed sudden deaths occurring without apparent 
cause in cases in which it was found to be enlarged. 

It is found to extend from slightly above the sternal notch 
to the third or fourth costal cartilage, and may be 2 inches or 
more in width, and it may weigh from V2 "^o 2 ounces. 

The thymus is best outlined by percussion, showing as a tri- 
angular area of dulness, irregular in outline, its base at the 
sternoclavicular margin and the apex at the second rib. 
The sides of the triangle extend slightly beyond the margin of 
the sternum, a little more so on the left than the right. The 
thymus and precordial area of dulness may coalesce. 

In children with an enlarged thymus, a condition of status 
lijmpJiaticus exists. The subjects are pale, anemic and pasty 
in appearance, and in older children, especially girls, the symp- 
toms are those of a chlorosis. There is usually a general en- 
largement of the superficial lymph nodes. They have but little 
resistance to infectious diseases, and are freciuently affected 
with tonsillitis and bronchitis. Sudden death in these children 
is not rare, especially as a result of a general anesthetic, more 
especially chloroform. The death may occur after the first few 
inhalations, during the operation or after the removal of the 
cone. This should always be borne in mind before an anes- 

469 



470 THE DISEASES OF CHILDREN. 

thetic is given, when a diagnosis of this condition of status 
lymphaticus is made. 

In cases of sudden death due to enlarged thymus, there is 
nothing else found at autopsy which can be looked upon as a 
cause. The only symptom which may be present is a sudden 
lividity, or cyanosis, followed by death. Direct pressure of the 
gland upon the trachea or the recurrent laryngeal or vagus 
nerve may be the cause of the death. 

No treatment is of avail. 

ACUTE ADENITIS. 

Definition. — An acute inflammation and enlargement of the 
l^anph nodes, local or general. 

Etiology. — This condition is secondary to an inflammation 
of adjacent structures, skin or mucous membrane. The extent 
of the inflammation and number of glands involved depends on 
the extent of area of skin or membrane involved in the inflam- 
mation. The bronchial lymph nodes may be primarily involved 
from tubercular invasion, by direct absorption of the bacilli 
from the bronchial mucous membrane or the intestine. 

]\Iesenteric enlargement occurs from absorption of tubercle 
bacilli and from acute inflammatory conditions of the intestinal 
tract. 

Inflammations of the mucous membrane of the nose and 
throat, mouth, the pharynx and larynx cause an inflammation 
of the deep cervical glands, and an inflammation of the scalp, 
face and ear, cause an enlargement of the superficial glands of 
the neck. Vaccination upon the leg may cause a severe inflam- 
mation of the inguinal glands. 

Pathology. — There is an acute congestion of the gland wdtli 
hyperplasia of the lymphoid structure. If there is direct in- 
vasion of the pus-producing organisms, a softening and breaking 
down of the gland usually occurs. 

Symptoms. — When secondary to other conditions, there is a 
rise in temperature, with swelling of the glands. If it is severe, 
redness of the skin over it develops, and it becomes quite tender 
and painful. An adjacent cellulitis may develop. In the acute 
cases there is temperature, irritability and restlessness. 



DISEASES OF THE LYMPHATIC GLANDS. 471 

Without suppuration the giand may remain firm and hard as 
long as the inflammation of the adjacent structures continues, 
and upon its relief the gland subsides. 

A relapse of the cause will again cause enlargement of the 
glands. 

Prognosis. — Except in tubercular glandular enlargement re- 
covery follows, but not always without suppuration and destruc- 
tion of the gland. In marasmic and cachectic children the con- 
dition is apt to develop into the chronic form. 

Treatment. — The cause must be sought and removed, disease 
of the scalp and the mucous membrane treated. 

Locally much good can be accomplished in the acute cases, 
Avithout apparent pus formation, by the application of 50 per 
cent grain alcohol poultices on absorbent gauze, protected by 
rubber tissue, or the application of pure ichthyol. Mud poul- 
tices do no good, save to hold the part fixed, thus saving pain. 

When much redness of the skin takes place and an area of 
softening, indicating pus formation, a free incision should be 
made and the gland drained. 

^Iiere they remain enlarged after subsidence of the con- 
tiguous inflammation, iodine in some form should be adminis- 
tered, the iodide of iron or hydriodic acid being beneficial. 

CHRONIC ADENITIS. 

This condition, in which there is a chronic inflammation and 
hyperplasia of the lymph nodes, usually follows an acute attack 
of inflammation. It may occur coincidently with a long-stand- 
ing and chronic inflammation of the skin, as an eczema of the 
scalp, or of the mucous membranes of the nasopharynx and 
pharynx. 

Symptoms. — The chief symptoms are the presence of en- 
larged glands, superficially situated about the body, as at the 
back of the neck, in the axilla and in the groin. These glands or 
groups of glands are hard, not tender, and show no tendency to 
break down or suppurate. The tendency is for them to remain 
stationary for some time, perhaps months, and then to gradu- 
ally become smaller. The process is simply one of a liyperplasia 
of the connective tissue without inflammation. There is no fever 



472 THE DISEASES OF CHILDREN. 

or inconvenience suffered by the child. It occurs most often 
under 10 years of age. In enlargement of the bronchial glands 
of sufficient size to cause pressure a cough is present. 

Diagnosis. — If the glands assume some size the condition 
becomes suspicious of a general blood trouble, as Hodgkin's dis- 
ease, or perhaps tuberculosis may be suspected. 

Treatment. — Remove or alleviate the cause. If a skin lesion 
treat it properly; if there are chronically enlarged tonsils or 
adenoids they should be removed; the nose should also receive 
attention. Potassium iodide is of great service in the form of 
syrup of the iodide of iron or hydriodic acid. Cod liver oil, 
not the extracts of the oil, given in the cool months, is of great 
benefit. Good and nourishing food must be given, change of 
surroundings, perhaps of climate, may be indicated. 

If the underlying bacterial cause can be ascertained the vac- 
cines might be used with benefit. 

ADDISON'S DISEASE. 

This is quite a rare disease in children. Comby has selected 
21 cases in literature; practically never seen under 10 years 
of age. 

It is characterized by the same train of symptoms as seen in 
adults, viz., bronzing of the skin, which is due to a deposit of 
pigment in the malpighian layer, progressive weakness of gen- 
eral muscular system and pulse, and gastrointestinal symptoms, 
as vomiting and diarrhea. The bronzing is chiefly of the ex- 
posed parts of the body, though the rest of the body may be 
as deeply pigmented. 

Pathology. — The chief change is a tuberculosis of the adrenal 
glands, with later tuberculosis in other organs, lungs, spleen, 
liver and glands. 

Diagnosis. — Pigmentation of skin from arsenic and exposure 
must be borne in mind; neither are attended with the general 
symptoms referred to. 

Prognosis. — This is always grave. 

Treatment. — Tonic and supportive treatment is indicated. 
From the location of the chief lesion, the suprarenals, adrenalin 
may be tried, given in 2 or 3 drops of 1 :1000 solution. Symp- 
tomatic treatment must be carried out. 



DISEASES OF THE LYMPHATIC GLANDS. 473 

CRETINISM (MYXEDEMA). 

Definition. — This is a condition which evidences itself by a 
remarkable backwardness of the child in its growth, of body and 
mind, an abundance of deposit of fat or mucin out of propor- 
tion to its bodily growth; in other words a persistence of in- 
fantilism. 

Etiology. — Nothing very definite is known of the cause. It 
has long been known to be prevalent in certain mountainous 
and limestone districts of Switzerland. This is looked 'on as 
the endemic form. Sporadic cases develop in any country, and 
a number have been reported in the United States. 

The thyroid gland is at fault, an insufficient secretion being 
the cause. It may follow the exanthemata, though just what 
the connection between them is we do not know. 

Pathology. — The thyroid gland is usually atrophied, or there 
may rarely be an enlargement, a goitre. Ossification is delayed. 

Symptoms. — There is no regularity in regard to the onset. 
It is usually insidious, coming on as a rule after the second year, 
but may appear soon after birth. These cases have the appear- 
ance of a dwarf, the extremities are short, the body apparently 
too large. The face is expressionless and idiotic when the tongue 
protrudes from the mouth. The mouth is constantly open, 
and there is constantly a flow of saliva. The eyes are expres- 
sionless and the eyelids baggy. The teeth are cut late, are irreg- 
ular in shape and decay quickly. There is an anterior curvature 
of the spine. The temperature is usually below normal, the 
skin baggy, harsh, cold and quite anemic and pale. The face is 
expressionless and the child apparently has no intellection what- 
ever. The broadening of the base of the nose is characteristic. 
The fontanelles, especially the anterior, are apt to be open. 
There is a "pot belly," which is quite marked. They usually 
show no sign of talking, and sounds made are harsh and un- 
natural. They may be able to stand, and if urged, to take a few 
steps, but usually show no inclination to walk. Other cretins 
may be in the family, usually, however, other children are nor- 
mal. 

Diagnosis. — A mental picture of this condition should make 
diagnosis easy. From Mongolian idiocy the diagnosis may not 



474 THE DISEASES OF CHILDREN. 

be so easily made. In the latter there is the Mongolian facies, 
they are more intelligent and not so deformed, the skin is not 
thickened, and the bridge of the nose not so wide. In this form 
the characteristic curving inward of the tip of the little finger 
is generally seen. Other conditions may be confounded, as 
infantilism, in which the infantile expression and size are main- 
tained, with an atrophy of the genitalia. The skin is soft but 
dry, and appendages unhealthy; the mind is infantile also. 

Infantilism of the Lorain type is described as a condition in 
which there is an imperfect development of the arterial sys- 
tem, causing insufficient nourishment. There is a premature 
ossification and stunted growth. A skiagraph of the hand shows 
ossification complete, while in myxedema there is a deficiency 
in the appearance of the nuclei of the carpal bones, and a failure 
of phalanges and metacarpals to unite. Thyroid treatment in 
this class of cases is unavailing. 

Prognosis. — These cases, if unrecognized and untreated, may 
live considerably beyond puberty, but maintain the idiotic look 
and mind, and dwarfed body. If the cases are recognized and 
treatment begun early, the results are quite brilliant. Good 
results have been reported when treatment has begun after 
puberty. 

Treatment. — As stated, the treatment of cretinism is brilliant 
in its results. Thyroid extract given internally quickly restores 
the child to normal. Dessicated thyroid extract can be given 
in tablet form, % to 3 grains at a dose at first, increased to 
5 grains at a dose, three times a day. To infants, l^ grain or 
1/2 gr. should be given at first, gradually increasing to 1 or 2 
grains. The thyroid should be given over a long period of time, 
at least four or five months, the dose then being given less often, 
with a few days' rest between. At first there may be a slight 
depressing influence from its use. 

The first improvement occurs in a week or so, and is in the 
facial expression. The tongue no longer appears too large for 
the mouth, the dribbling of saliva ceases, the skin loses its 
myxedematous feel and appearance, the hair looks more natural, 
delayed teething takes place, the mental condition seems to 
quickly assume its proper proportions. 



DISEASES OP THE LYMPHATIC GLANDS. 475 

After the discontinuance of the regular dose of thyroid for 
several weeks, it is again given once or twice a week for several 
months, and for a long time the child should be kept under 
observation and the thyroid given if indications of mental dul- 
ness or sluggishness again appear. It may be necessary to con- 
tinue the treatment by thyroid for life. 



CHAPTER XX. 

DISEASES OF THE GENITOURINARY SYSTEM. 

THE URINE. 

The urine of a healthy infant should be nearly colorless, 
should not stain the napkin, and of a low specific gravity, from 
1004 to 1010. In the new-born the amount passed is much 
less than in older children, during the first 24 hours, probably 
not averaging more than an ounce. During this time there is 
apt to be a relatively large amount of the salts of urea, which 
appears as a very fine sand, and the urine is much thicker than 
normal. The uric acid may collect as infarcts in the kidney and 
cause a suppression of urine until dislodged and washed out. 
The failure to pass urine during the first 24 hours is an indica- 
tion for the administration of water, both by the mouth and 
the bowel, to thoroughly flush the kidneys. 

Uric acid remains relatively large in amount in proportion 
to the other urinary constituents during childhood. 

It is often difficult to obtain a sample of urine from an infant 
for examination, and next to impossible to obtain a 24-hour 
specimen. In male infants, b}^ attaching a rubber condom to 
the genital organs, including scrotum and penis in the neck of 
the rubber, and fastening by tapes around the waist, enough 
urine for a chemical and microscopic examination can easily 
be obtained. In girl babies this is often much more difficult. 
The appliance suggested by Chapin is a most useful one, and 
can be applied to the vulva and retained by tapes tied to the 
thighs or waist and worn without discomfort until the sample 
needed is obtained. The end of the urinal is put in a bottle, 
or a rubber tube attached, and its free end placed in a bottle. 

Placing the child upon a rubber sheet without napkin or pro- 
tective dressing, or placing a sterile sponge or piece of gauze 

476 



DISEASES OF THE GENITOURINARY SYSTEM. 477 

over the vulva or the penis, which as soon as wet is squeezed 
into a test tube, later filtered, may be successful if persisted in 
long enough. 

The difficulty attending the obtaining of a sample of urine 
has unquestionably been the cause of neglect in the examina- 
tion of the urine of infants in the past, but even if catheteriza- 
tion must be resorted to in order to obtain a specimen for exam- 
ination, it should be done. Many obscure cases can be cleared 
up if the urine is examined, and too great emphasis cannot 
be laid upon it. 

During the third month it is estimated 200 cc, of urine are 
passed in 24 hours with a specific gravity from 1004 to 1010, 
and from 1 to 2 grams of urea; during the sixth month, 250 
cc. of urine, in 24 hours ; specific gravity, 1006 to 1012 ; during 
the twelfth month, 400 cc. in 24 hours, with 11 grams or urea ; 
from two to five years, 500 to 800 cc. in 24 hours; five to eight 
years, 600 to 1200 cc. in 24 hours; eight to fifteen years, 1000 
to 1500 cc. in 24 hours. The urine gradually increases in 
amount to 1000 cc. in the tenth year, with a specific gravity 
of 1015, and 20 grams of urea. 

ALBUMINURIA. 

Normal urine contains nucleoalbumin, but not serumalbumin, 
and when serumalbumin is present it should be considered 
abnormal, and the indication of pathologic conditions. Serum- 
albumin is sometimes, but not with any regularity, found in 
the urine of infants during the first week after birth, but its 
persistence is indicative of abnormalities, such as nephritis, the 
acute and chronic parenchymatous forms, pus in any organ or 
cavity, etc. Albumin is quite regularly present during the 
acute diseases of childhood. 

Croftan ^ describes an intermittent albuminuria and a cyclic 
albuminuria. He gives as causes of the first, nervous influences, 
exposure to cold, diet and overexertion, and describes a dyspeptic 
albuminuria, which is present in intestinal disorders and dila- 
tation of the stomach. This form of albuminuria if continued 
for a long period leads to true nephritis. 



1 Croftan: Clinical Urolorr. 



478 THE DISEASES OF CHILDREN. 

The urine of the infant is but faintly acid, often alkaline 
in reaction. 

CYCLIC, or FUNCTIONAL ALBUMINURIA. 

This condition is not infrequent in older children, especially 
about the age of puberty. As the name implies, albumin may 
be found in the urine during certain hours in the day, and at 
other times it is absent. 

Etiology. — It is seen most often in boys. It has been 
thought to be due to severe and fatiguing exercise; cold and 
prolonged bathing; exposure to cold; continued indigestion; 
lithemia; but Croftan believes only two factors are to be con- 
sidered in its etiology, viz., changes in the position of the body 
and muscular fatigue. The theory of the postural cause is that 
the albuminuria "is due to a certain reactive insufficiency of 
the circulatory apparatus," that it is a "manifestation of a 
vasomotor fatigue." 

Pathology. — This form of trouble has no pathology, as there 
are no pathological changes. When an albuminuria is due to a 
change in the kidneys, the condition is no longer a functional 
trouble. 

Symptoms. — Usually the albuminuria is discovered accident- 
ally, as the child may not present any symptoms. The chief 
and only symptom perhaps may be an indigestion, and if per- 
sistent long, an anemia. 

The urine does not show albumin continuously as indicated 
by the name given the trouble. No albumin may be present on 
arising, but by noon it is shown to some extent, and persists 
until night, when the amount gradually decreases, a prolonged 
stay and rest in bed may clear the urine entirely. An increase 
in the urinary salts may be seen, uric acid, .urates and oxalates. 

Diagnosis. — In every case of albuminuria the symptoms and 
urinary findings should be carefully weighed before a diagnosis 
is made. Frequent and careful chemical and microscopic exam- 
ination of the urine should be made to exclude a nephritis. The 
presence of casts in a centrifugalized specimen of urine is suffi- 
cient to exclude functional albuminuria. 

Prognosis. — Where the diagnosis can be made positively the 
prognosis is favorable. 



DISEASES OF THE GENITOURINARY SYSTEM. 479 

A persistent albuminuria should be regarded with suspicion, 
as indicative of organic changes in the kidney. 

Treatment. — Eest in bed while the cjuantity of albumin is 
large, careful diet, limiting the amount of nitrogenous foods; 
regular and graduated exercises, never to the point of fatigue, 
and not violent at any time. Occasional blood pressure tests 
should be made. 

Occasional doses of calomel are of great benefit, with a mild 
saline following; and as suggested by Croftan ''on the basis 
of the vasomotor fatigue theory, cardiac tonics are indicated, 
and good results have been obtained by this therapy." 

Change in climate may be necessary, to a warmer, more 
equable one. 

PYELITIS. 

Definition. — An inflammation of the lining membrane of the 
pelvis of the kidney. When the inflammation extends to the 
tubules of the kidney it is a pyelonephritis ; when an accumula- 
tion of pus in the kidney takes place, a pyonephrosis. 

Primary and secondary pyelitis have been described, but it 
is difficult to draw the line between the two. 

Etiology. — The presence of a calculus in the pelvis of the 
kidney may act as an exciting cause. It occurs more frequently 
in female than in male infants, and is probably due to an exten- 
sion of bacilli from the vulva and vagina to the pelvis of the 
kidney without a coincident urethritis or cystitis. The chief 
infecting organism is the colon bacillus, which may gain en- 
trance direct from the intestinal tract. A diarrhea may precede 
the acute symptoms of the pyelitis. It occurs at any age, but 
in my experience most often in female infants between 6 and 
18 months of age. 

It may complicate the exanthemata, pneumonia or diphtheria 
or a general pyemic state. 

Pathology. — The pathological changes are those of acute in- 
flammation of a mucous membrane, congestion, swelling with 
possibly punctate hemorrhage. Pus is formed and is washed out 
with the urine. If the accumulation of pus is greater than is 
thrown off in this way, it distends the pelvis and calices and 
forms a pyelonephrosis. 



480 THE DISEASES OF CHILDREN. 

Symptoms. — The onset is usually sudden and the symptoms 
obscure. The chief symptom is a persistent and irregular tem- 
perature, usually to 105° F., ushered in often with a chill or 
evidences of chilliness, manifested by blueness of the skin, cold 
hands and feet and feeble circulation. The temperature may 
show a decided remission or remain persistently high with but 
slight remissions, often with sweats. 

There may be a preceding gastrointestinal disturbance or 
vomiting without any bowel disturbance. 

No symptoms are present as a rule referable to the kidneys, 
no tenderness or pain in the loin or abdomen, though occasional 
cases are seen evidencing considerable pain in the back. Unless 
the condition is recognized by a careful examination of the 
urine the case may continue indefinitely, showing a continuous 
temperature, anorexia, emaciation, restlessness and profound 
anemia. 

The urine is acid, contains albumin and on microscopic ex- 
amination, a large number of pus cells is found. The urine is 
diminished in amount, is apt to be cloudy from the pus and 
kidney epithelia present. The epithelia are from the kidney 
pelvis and the ureter. If the condition has existed long, hyaline 
casts may be found, chiefly of large size. Many actively motile 
bacteria are present. 

In the so-called secondary form of pyelitis in which a calculus 
is present, there is pain and tenderness, renal colic and blood 
in the urine. Bacteriological examination should be made in 
long-standing cases, looking especially for the tubercle bacillus. 

In one of my cases the microscopist reported the presence of 
foreign bodies resembling the ova of an intestinal parasite, and 
it was puzzling to several who saw it, until I recalled the fact 
that lycopodium powder was used on the buttocks, and the sus- 
pected ovum proved to be the seed pod of the lycopodium. 

Diagnosis. — This is not always easy, but w^ill be made much 
more readily and often if systematic examinations of the urine 
are made. Every case of sudden temperature, in which diseases 
of the gastrointestinal tract and lungs can be ruled out, a 
pyelitis should be suspected, and a careful urinal.ysis made. 
The urinalysis is not complete without a microscopic examina- 



DISEASES OF THE GENITOURINARY SYSTEM. 481 

tion. Pus, kidney cells, albumin, a highly acid urine and 
bacteria make the diagnosis certain. A vulvovaginitis must be 
excluded, but in this, as a rule, there is no fever. 

Prognosis. — In uncomplicated pyelitis the prognosis is good. 
It is influenced by the time which elapses between its onset and 
the making of the diagnosis. Its course under treatment is 
usually about two weeks, and recovery is the rule. 

Treatment. — Hexamethylenamine gives almost universally 
good results. It is administered in 3 grain doses to a child of 
one year, every three hours, with as much water during the 24 
hours as possible. 

If there is a complicating enterocolitis a preliminary dose of 
calomel and castor oil should be given, followed by a colon 
injection of normal salt solution, and a subsequent daily evacu- 
ation obtained. To neutralize the urinary acidity. Holt recom- 
mends potassium citrate, 2 or 3 grains, well diluted, every three 
hours. Acetate of potassium may also be used. 

Unless there is a decided abnormal condition of the bowels, 
no change is made in the diet; milk, however, being preferred 
to any other article. 

In cases which do not promptly respond to urinary anti- 
septics the use of the vaccines offer the best possible results. 
A careful bacteriologic examination of the urine is made and 
the bacteria identified. If of the pure colon strain, the stock 
colon bacillus vaccine can be used or if preferred, and a com- 
petent laboratorj^ expert is available, an autogenous vaccine can 
be made and administered. 

RENAL CALCULUS. 

Synonjnn. — Stone in the kidney. 

Etiology. — Stone in the kidney in children is infrequent. 
They have their origin in uric acid, though they may contain 
oxalate of lime also. Large calculi are comparatively rare. 
Bacteria and cellular detritus in an inflammatory condition of 
the pelvis of the kidney may form the nidus for a stone. 

Symptoms. — Small calculi, more like sand, may form in the 
pelvis of the kidney and be washed free into the ureter and 
bladder, and passed from the bladder with the urine. These 



482 THE DISEASES OF CHILDREN. 

frequently cause pain in their passage through the ureter, evi- 
denced by restlessness and crying, a diagnosis of the condition 
not being made until the sand or calculus is passed from the 
bladder and found on the napkin or in the vessel. In the male 
the passage of the sand through the urethra is attended with 
great pain, and if the child is large enough, referred to the end 
of the penis. I have seen one stone which had evidently lodged 
for some time in the glans portion of the urethra and grad- 
ually increased in size there, as it took exactly the shape of 
that portion of the urethra. An examination was made to ascer- 
tain the cause of the painful urination and this stone found, 
very slightly distending the meatus. It was fished out with a 
fine hemostatic forceps and complete relief afforded. 

If the stone is retained in the pelvis of the kidney a pyelitis 
and pyonephrosis results. Absorption takes place, chills, sweats, 
wasting, prostration and great pain, caused by the effort to 
pass it on through the ureter, too small to receive it. 

If renal calculus is suspected an X-ray photograph should be 
taken. 

Treatment. — Renal colic is very painful and usually requires 
anodynes for its relief. Opium in some form is necessary, 
paregoric or the deodorized tincture, in the minimum dose, 
repeated if need be. Relaxation from a general hot bath is of 
service. Hexamethylenamine is of great service in cases with 
infection from pyelitis. In the presence of very great pain, 
sepsis, chills, etc., the condition becomes a surgical one, and 
early operation for drainage should be performed. 

Liberal Avater drinking in this condition is of the greatest 
benefit. 

PERINEPHRITIS. 

Definition. — This is an inflammation of the loose connective 
tissue surrounding the kidney, with or without the formation 
of pus. 

Etiology. — It may be primary, due to trauma, exposure and 
cold, or secondary, following the acute infectious diseases, pye- 
litis or pyonephrosis, vertebral diseases, or renal calculus. 

Pathology. — The loose connective tissue surrounding the 



DISEASES OF THE GENITOURINARY SYSTEM. 483 

kidnej^s undergoes inflammatory reaction with frequent local- 
izing of the process and the formation of an abscess. 

Symptoms. — The onset is sudden, with a decided chill and 
pain located in the lumbar region of the affected side. The pain 
is reflected along the psoas muscle to the inguinal region, groin 
or the thigh. There is tenderness over the loin and pain is 
increased by walking or bending forward, and a decided curva- 
ture of the spine may be present. 

There is a rise of temperature with septic symptoms and 
digestive disturbances, chiefly vomiting, in the acute cases. It 
may begin slowly with some pain and tenderness, increased on 
movement. If the abscess forms the pus will travel toward the 
least resistance, may open on the skin, or follow the psoas muscle 
and open on the thigh. 

Diagnosis. — This must be made from pyelitis. In perine- 
phritis no pus cells in the urine; from hip-joint disease, by 
limited motion of leg, and atrophy of the muscles of the thigh, 
and its slow onset; from Pott's disease of the spine, with psoas 
abscess. 

Treatment. — Absolute rest in bed ; light diet ; incision of the 
abscess sac, under anesthesia, if it is thought advisable. An 
exploratory puncture can be utilized at any time. Application 
of an ice bag before pus has localized will be beneficial. 

ACUTE PARENCHYMATOUS NEPHRITIS. 

Synonyms. — -Acute Bright 's disease; acute exudative nephri- 
tis; catarrhal nephritis; acute desquamative nephntis, acute 
tubular nephritis. 

Etiology. — This form of nephritis may be primary or sec- 
ondary, but is more frequently secondary. Primary nephritis 
is rare. Holt has collected 24 cases from his practice and from 
literature. I have seen but one case in my own practice with 
recovery. Undue exposure is the most frequently reported 
cause of the primary form, though no cause may be found. 

The secondary form is generally due to one of the exanthemata 
or infectious diseases, scarlet fever and diphtheria being the 
most frequent causes. In various epidemics of scarlet fever 
the number of cases of complicating nephritis var}^ from 5 per 



484 THE DISEASES OF CHILDREN. 

cent to 70 per cent. It may occur as a complication in septic 
conditions from any cause, notably in gastrointestinal diseases, 
in which the colon bacilli and streptococci are present. The 
pathological condition may be caused by the organisms them- 
selves or their toxins. Among other causes may be exposure 
to cold, and the continued administration of certain drugs, hav- 
ing an irritative effect upon the kidney as potassium chlorate 
and the phenols. 

The active cause of the inflammatory condition of the kidney 
in the infectious diseases is the irritating effect of the toxins 
on the parenchyma of the kidneys. 

Pathology. — The epithelia are degenerated, the kidney 
stroma infiltrated to such an extent that the kidney is enlarged 
and softened. The capsule is not adherent. The surface of the 
kidney is deeply injected, as are the pyramids on section. The 
tubules are dilated and contain blood cells and epithelia. 
Under the microscope the tubular cells show degeneration and 
cloudy swelling. 

Symptoms. — Systemic. — The onset is generally abrupt. In 
the very young uremic symptoms may be manifest early by the 
attack being ushered in by a convulsion; vomiting and some- 
times diarrhea are present early. If occurring as a complica- 
tion of the exanthemata, the symptoms begin about the third 
week. There is a sharp rise of temperature, the pulse corres- 
pondingly rapid, and the tension quite high. Edema is present 
early, in the face, perhaps only the eyelids, the legs and thighs. 
Ocular symptoms may be present early, spots before the eyes or 
even blindness. Headache is prominent and anemia quickly 
appears. 

Focal. — The urine is very scant, cloudy and high colored. 
The specific gravity is high, and albumin is present in consid- 
erable quantit^^, usually larger if the amount passed is small. 
The quantity of urea is greatly diminished. 

MicroscopicaUij, all varieties of casts, large and small, are 
found, and free-blood cells also. If the urine is abundant, the 
casts may not be as numerous. 

In the secondary form the symptoms usually present late in 
the disease: After having been afebrile the temperature rises 



DISEASES OF THE GENITOURINARY SYSTEM. 485 

again, it is more irregular, and not quite so high, the child 
quickly appears sick again, after an apparently satisfactory 
convalescence. There is vomiting, headache, restlessness, edema, 
and much the same urinary symptoms as in the primary form. 

The duration in the primary form is from three or four days 
to two weeks, and in the secondary form a slightly longer period. 

An improvement is first noticed in the amount of urine passed, 
lessened amount of albumin, fever, renal derivatives, and grad- 
ual improvement in all the symptoms. 

Prognosis. — The younger the children the graver the prog- 
nosis. Either form of nephritis is very serious in the young. 
Albumin and casts may both persist for some time after the 
acute symptoms subside. 

Complications. — Endocarditis, pericarditis with effusion; 
meningitis; edema of the glottis or pneumonia may occur. 

Treatment. — Prophylaxis. — During the infectious diseases, 
prevention from exposure to cold ; a carefully regulated diet in 
which milk should predominate ; regular actions from boAvels ; 
plenty of water to flush the kidneys; keep the skin active by 
warm baths. Close confinement to bed in these infectious cases 
may often prevent kidney involvement. 

Management.^ — Diagnosis having been made, active treat- 
ment must begin with promptness. The following indications 
are to be met: (a) Relieve kidneys of the extra work of drain- 
ing the serum from the tissues, as well as from excreting the 
retained products of tissue metamorphosis; (h) restore the 
kidney to its normal condition; (c) by careful and intelligent 
medication and diet prevent further damage to the diseased 
organs; (d) rest in bed. 

Diet. — The bulk of the diet, though not exclusiveh^, should 
be milk, whole, or in the form of buttermilk, made from fresh 
milk. To this should be added well-cooked cereals and toast 
with butter. Plenty of water should be given also. 

Medicinal. — Calomel is a sheet anchor in the treatment of 
acute nephritis ; it is an admirable diuretic, as well as acting 
upon the upper bowel. It should be repeated at intervals of 
several days. The initial dose should not be less than 2 grains. 
Later salines, citrate of magnesia, rhubarb and soda, cascara 



486 THE DISEASES OF CHILDREN. 

sagrada, or compound jalap powder, can be tried. Nitroglyc- 
erine in high temperature, vomiting and high-tension pulse. 
Chloral may be given for the nervous symptoms. 

Digitalis is of great service, relieving the heart and assisting 
the kidney also. Infusion is of service; fat-free digitalis yields 
good results, 5 minims to child of one year; strychnia, caffeine 
and nitroglycerine can be used to advantage for the heart. 

Water, by the mouth if possible, enteroclysis or hypodermo- 
clysis, is of great assistance. 

If edema is great, diaphoretic measures can be used to advan- 
tage. Hot wet-packs and the hot-air apparatus bring on a whole- 
some sweat, with relief of symptoms promptly. Pilocarpine 
should be used with great caution. 

Dty Clips over the loin may aid in relieving renal congestion. 
Blood-letting has been advocated, and in one of my cases was 
used with decided benefit. From 2 to 5 ounces can be removed 
without deleterious symptoms, in child of three years. 

In convalescence iron is early indicated in order to combat 
the anemia, which is usually present. At this time acetate or 
citrate of potassium can be used to advantage. 

The urine must be constantly watched and the first evidence 
of increasing trouble instead of an improvement calls for 
prompt attention. 

CHRONIC NEPHRITIS. 
Types. — Chrome par end ly mat o us nephritis. Chronic inter- 
stitial nephritis. 

Chronic Parenchymatous Nephritis. 

Etiology. — Comparatively rare at any age of childhood, more 
common late. It occurs more often as sequel to the acute 
nephritis than as a primary condition. Prolonged sepsis, alco- 
holism, congenital syphilis, malaria, chronic gastrointestinal in- 
flammations, etc., are mentioned as causes. 

Pathology. — This is essentially the same as in adults. There 
is an enlargement of the kidneys due to new connective tissue, 
and they are white and nodular in appearance. 

Symptoms. — Usually this form originated from the acute 
variety there simply being an amelioration of the acute symp- 



DISEASES OF THE GEXITOURIXARY SYSTEM. 487 

toms. or perhaps a disappearance of them entirely for a short 
while, and their reappearance in this form. 

The symptoms are insidions, until the dropsy is a feature, no 
special attention being given the kidneys. Tliere is headache 
and neuralgia, lassitude or weariness, loss of appetite, vomiting, 
anemia. The dropsy varies in amount, but usually is cpiite 
marked, especially of face and extremities. It may be present 
for a time and disappear. 

The urine is usually diminished in quantity, though it may 
be normal or increased. Specific gravity is low. and albumin 
present in considerable amount. The total urea output is 
greatly reduced. All the renal derivatives may be present, but 
granular epithelia are more numerous. The duration is very 
variable. It mav last for years. It is essentially a chronic 
disease. 

Diagnosis. — This may be very difficult. It will certainly be 
made much oftener when the profession as a whole realizes the 
importance of frecpient examination of the urine in all cases 
of illness in children. Any progressive anemia with digestive 
disturbance, loss of weight and beginning edema should make 
one very suspicious of the kidneys, and call for an examination 
of the urine. 

Prognosis. — The outlook is decidedly bad. The course of 
the disease is chronic with occasional acute exacerbations. It 
is usually one of these acute attacks which carries the child off. 
Some cases apparently recover after months of invalidism. 

Treatment. — General Management. — Protection from ex- 
posure is most essential. AYarm, part- wool underclothing should 
be worn. Careful regulation of the diet, milk, carbohydrates, 
cooked fruits, buttermilk and cereals can be used. Eed meats, 
eggs, fish, animal broths, should be avoided. The bowels should 
be carefully watched. Occasional purgation is indicated with 
irrigation of the colon and warm baths : water should be given 
freely. 

Renal decapsulation, according to the operation suggested by 
the late Dr. G. M. Edebohls, has been advocated, several suc- 
cessful cases being on record. It is an operation which should 
be done with great caution. 



488 THE DISEASES OF CHILDREN. 

Chronic Interstitial Nephritis. 

This is an extremely rare condition in older children and 
practically unknown in infants. 

Etiology. — Syphilis, malaria, tuberculosis, have been named 
as causes. 

Pathology. — These kidneys are smaller than normal. The 
capsule is adherent and there is a proliferation of connective 
tissue. If the connective tissue presses upon the tubules a 
condition of hydronephrosis is caused. 

Symptoms. — This form is more insidious than the others. 
The child loses in Weight continuously and is anemic. Gastro- 
intestinal symptoms are prominent, vomiting is frequent; head- 
ache is present, and eye symptoms, as double vision, specks 
before eyes, or complete blindness, may occur. There is usu- 
ally no rise in temperature, but there is a high-tension pulse, 
and the left heart shows dilatation. 

The urine is increased in quantity and specific gravity is 
low. Albumin is present in small quantities and may be only 
occasionally found or absent entirely. The principal casts pres- 
ent are the hyaline, though the other varieties, in the pres- 
ence of an acute exacerbation may be found. 

Prognosis. — This is always bad. The tendency is to a fatal 
termination, though it may show an improvement occasionally. 
The duration may be two or three years. 

Treatment. — Not a great deal can be accomplished save the 
care of the child, protection from exposure and carefully regu- 
late the general functions of the body. The diet should be 
chiefly milk, but occasional meals of more or less general char- 
acter must be given, if anemia is a prominent symptom. 
Change of climate is often of great benefit. 

TUMORS OF THE KIDNEY. 

Varieties. — Benign tumors of the kidney are very seldom 
seen. The vast majority of this form of growth are malignant, 
and the commonest variety is a sarcoma. Any portion of the 
kidney may be primarily involved, with secondary involYeraeiit 



DISEASES OF THE GENITOURINARY SYSTEM. 489 

of other organs, as the liver, spleen or lungs. A variety of 
growth has been described by one author as embryonal 
adenosareoma. 

Etiology. — These growths are essentially peculiar to children, 
occurring usually between six months and four and a half or 
five years of age. It is rare to see one in children over five 
years of age. It does not occur oftener in one sex than another. 
The left kidney seems to be more often affected. The direct 
cause is not known. 

Symptoms. — The condition may not be recognized until the 
growth is visible to the eye. Preceding this time the cachexia 
is quite marked, there is apt to be pain and occasionally bloody 
urine. 

In the presence of the latter conditions a careful palpation 
should be made of the abdomen, and the tumor will probably 
be found. At first its growth is slow, but when easily palpable 
the tumor enlarges with greater rapidity, and may apparently 
fill the whole abdominal cavity in a short while. The feel of 
the tumor is usually soft, not fluctuating, but a distinct give to it. 

Bloody urine . is a very common symptom. It may be 
demonstrable only by the microscope, but is present in prac- 
tically all cases. Albumin is present, principally because of the 
blood. Hyaline casts are sometimes found. 

The first symptom to call attention to the child may be a 
distinct cachexia, a something in the countenance and the skin 
which usually suggests malignancy, a different color from the 
anemia of tuberculosis. The child loses flesh rapidly and the 
prominent abdomen soon becomes a marked symptom. 

Pain more or less severe is present in practically all cases. 
It may be simply a dull but persistent ache or a severe darting 
pain, enough to make the child cry out. 

Diagnosis. — A diagnostic sign usually present is the locali- 
zation of the colon, shown by a tympanitic note over the surround- 
ing dull area. 

Kidney tumors are the most frequent of abdominal tumors 
in children. 

Prognosis, — The course of malignant tumors of the kidney is 



490 THE DISEASES OF CHILDREN. 

always fatal if not operated upon. Early operation yields 
good results. Unoperated cases die within six months or two 
years. The earlier the diagnosis and operation the greater the 
chance of recovery. 

Treatment. — This is essentially surgical as no other treat- 
ment offers any results. Pain usually requires anodynes; 
paregoric, heroin, codeine or morphia may be given. 

Removal of the kidney and ureter for some distance offers 
the only hope of recovery, and the earlier this is done the better 
the outcome. 

HYDRONEPHROSIS. 

Definition. — This is either congenital or acquired, and is 
either a cystic degeneration of the kidney or an accumulation 
of urine in the pelvis of the kidney from an obstruction of the 
ureter. 

Etiology. — The obstruction of the ureter at any point in the 
ureter, may be caused by the lodgement of a stone from the 
kidney or contraction of the vesical orifice of the ureter. Ob- 
struction of the ureter from pressure by tumors of other organs 
may be a cause. 

Pathology. — A tubule of the kidney may become blocked and 
dilated, forming the beginning of a cyst. If obstruction of the 
ureter is present the pelvis of the kidney becomes dilated and 
the cortical portion of the kidney pressed upon until it is a 
thin shell. The kidney is larger than normal, but not as large 
as a malignant growth. A double hydronephrosis may be pres- 
ent in which case the obstruction is most likely low down. 

Symptoms. — These are very vague, and usually no diagnosis 
is made until the tumor is felt. It occurs later than the malig- 
nant growths as a rule. The presence of the urinarj^ findings 
of nephritis may obscure the true diagnosis. 

Prog'nosis. — Without surgical intervention the prognosis is 
grave, and in the double variety the end comes quickly. 

Treatment. — This is entirely surgical, and when but one 
kidney is affected, a nephrectomy being indicated in all cases. 
Drugs have no place in the treatment. 



DISEASES OF THE GENITOURINARY SYSTEM. 491 

ENURESIS. 

Synonyms. — Bed-wetting ; incontinence of tmne. 

Definition. — This is a continuance of the infantile habit of 
vesical incontinence into the third year. 

Etiology. — The control of the bladder is a complex phe- 
nomenon. AYith distension of . the bladder the impulse for 
evacuation passes from the nerves in the bladder wall to the 
cord and brain, and the impulse to the muscles of the bladder 
is carried back through the nerves; this causes relaxation of 
the vesical sphincter, and the contraction of the muscles of the 
bladder follows. 

Enuresis occurs in various organic diseases of the central 
nervous system; from irritation of the nervous centers, in the 
cord or brain, and of the nerves in the bladder ; inflammatory 
change in the bladder mucous membrane; congenital bladder 
malformations; abnormal urine, especially a hyperacidity; too 
free taking of fluids at bed time ; vesical calculus ; phimosis ; 
urethritis; vulvovaginitis and urethritis; extreme nervous con- 
ditions, especially chorea ; anemia ; constipation ; weakness of 
the sphincter vesicae. 

The oldest child I have seen with enuresis was a boy of 
13. Enuresis may be nocturnal or occur only during the day, 
or may occur both day and night. 

Symptoms. — The chief symptom is the involuntary passage 
of urine, which may occur once or several times during the 
night. If it occurs only during the day the child may be able 
to retain the urine only an hour or so. Frequently an acci- 
dental passage of urine occurs while the child is intent upon 
its play, and this should not be classed as an enuresis. 

The habit may continue until puberty, if treatment is not 
instituted. 

Prognosis. — The earlier the treatment is begun, the better 
the results; the correction of malformations yields prompt re- 
sults. If there is an organic brain lesion the prognosis is not 
good. 

Treatment. — Examine carefully into any cause, mechanical 
or otherwise, which is removable, and first correct this. Usually 
no other treatment is needed. Reflection of the prepuce or cir- 



492 THE DISEASES OP CHILDREN. 

cumcision in severe phimosis relieves one source of irritation, 
and while of itself does not cure many cases, is a great help. 
Build up the child; correct dietary indiscretions; limit the 
amount of water drank after 6 o 'clock in the evening ; awaken 
the child at 10 o'clock to empty the bladder; assist it to sleep 
upon the side and not upon the back by wearing a knotted 
towel about the waist with the knot in the lumbar region; raise 
the foot of the bed to cause the urine to distend the summit 
of the bladder and not make undue pressure upon its neck; 
cool bathing, followed by a rub, is beneficial also. A bland diet, 
especially at night, should be insisted on. 

Medicinally belladonna gives the best results, and it can be 
given in the form of the tincture, the initial doses of 1 drop 
for each year of age, three times a day, increased a drop a day 
until the physiological effect is obtained. The dose is then 
decreased 10 per cent and kept at this for a week or so, then 
decreased 1 drop a day until it is discontinued. 

Hexamethylenamine, salol or citrate of potassium may be of 
benefit. Ergot in small doses is of value in cases due to weak 
bladder muscle, five minims of the fiuid extract three times 
a day to a child five years old. 

Atropia can be given as follows : 

IJ Atropiae sulphatis gr. ss 

Aquae destillat Ji 

M. et ft. solutio. 
Sig. One drop for each year of the child's age at 4, 5 and 6 o'clock in 
the evening. Strychnia can be added to the above prescription in proper 
dose. 

PHIMOSIS. 

A congenital phimosis, or contracted prepuce, exists in all 
male children, but with the growth of the glans penis, the adhe- 
sions are loosened and the accumulation of smegma behind the 
corona glandis separates them at this point. 

If from birth to the fourth week the prepuce is pushed back 
a little farther, daily, by the end of that time it can be easily 
pushed back over the corona glandis and the smegma removed. 
This preliminary and complete stretching and reflection dilates 
the prepuce sufficiently to make the complete uncovering of the 



DISEASES OF THE GENITOURINARY SYSTEM. 493 

glans easy, and obviates the necessity for circumcision. This 
reflection should be repeated once a week, some vaseline placed 
behind the corona and on the glans and the fore-skin replaced. 
The necessity for replacement of the foreskin promptly after 
its reflection should always be borne in mind as a paraphimosis 
is easily produced. 

Symptoms. — There may be no symptoms except pain on void- 
ing urine or straining at that time without pain. The straining 
may be so great as to cause a prolapse of the rectum. Reflex 
symptoms are not uncommon when adhesions are present. I 
have seen one boy presenting symptoms of hip-joint disease 
which were completely relieved after the preputial adhesions 
were broken up. Night terrors and epileptiform convulsions 
may be caused by phimosis as well as choreic symptoms. 
Enuresis has been attributed to phimosis, but other observers 
report little relief from this condition by circumcision or cor- 
rection of the trouble by reflection of the prepuce. 

Treatment. — None of these symptoms will present if early 
retraction is done, but if there is a pin-point preputial orifice 
which is very tight a circumcision should be done, with the 
entire removal of the prepuce. A dorsal incision of the prepuce 
should never be performed in lieu of a circumcision. 

PARAPHIMOSIS. 

This usually occurs in infants as the result of a reflection 
of the prepuce, the foreskin being allowed to remain behind the 
corona giandis too long. As a result a strangulation occurs, 
and a swelling of the folds of the prepuce quickly takes place. 
The swelling may be very great, the skin and mucous membrane 
become reddened, and later may become black if the condition 
is not relieved. Considerable pain is present and there may be 
difficulty in urination. 

Treatment. — Manipulation may succeed in reducing the 
deformity. The penis is encircled just back of the corona 
giandis by the fingers of one hand and the other holds the 
glans, firm pressure being made simultaneously for several 
minutes. The position of the hands is then changed and pres- 
sure is made upon the glans and corona giandis by the thumbs 



494 THE DISEASES OP CHILDREN. 

and index fingers, an attempt being made at the same time by 
the other fingers to draw the foreskin forward. 

If these manipulations fail, while the penis is flaccid and 
much of the blood has been forced out by the manipulations, 
the constricting bands are divided on the dorsum of the penis 
in the median line, the reduction then being easily accomplished. 

HYDROCELE. 

Definition. — An accumulation of serum in the sac surround- 
ing the testicle or in the peritoneal extension in canal of Nuck 
of the female. It may be congenital or acquired. 

Symptoms. — In hydrocele of the tunica vaginalis there is a 
gradual enlargement of one side of the scrotum, occasionally of 
both sides. The tumor is tense, fluctuation can be demonstrated, 
it is translucent, and can not be reduced into the abdominal 
cavity. 

The congenital variety is reducible, the opening at the internal 
ring being patent. 

Treatment. — No treatment may be needed, the fluid being 
spontaneously absorbed. "When very tense aspiration should be 
performed, the inside of the sac wall being rubbed with the 
point of the canula, and an obliterative traumatic inflammation 
set up. The practice of injection of carbolic acid into the sac 
is not to be commended in children. 

BALANITIS. 

This is an inflammation of the mucous membrane covering 
the prepuce and glans penis. 

Etiolog-y. — Neglect of the foreskin, uncleanliness, infection, 
trauma, masturbation, urethritis with confining of the secre- 
tions, and decomposition of the smegma. It occurs most often 
in a phimosis. 

Symptoms. — The first symptom noted will be an enlargement 
of the penis, principally near the end of the foreskin. If there 
is a phimosis the end of the prepuce seems smaller than usual. 
A discharge may be noticed, in the absence of a urethritis, com- 
ing entirely from the mucous membrane of the prepuce and 
glans. It may be due to a decomposition of the smegma, or 



DISEASES OP THE GENITOURINARY SYSTEM. 495 

an infection after reflection. I have seen one case in which a 
small abscess formed behind the corona from this cause, adhe- 
sions having formed around the pus and limiting it to a small 
area. Reflection of the prepuce, breaking up of the adhesions 
and cleanliness caused a prompt cure. 

Treatment. — Perfect cleanliness is indicated. Boracic acid 
solution is effectual. Circumcision should be performed where 
there is enough constriction to prevent free exposure of the glans 
for cleansing, not however until all inflammation has subsided. 
It may be necessary to make a dorsal incision to accomplish 
free drainage, with a complete circumcision later. 

URETHRITIS. 

This is an infection of the urethra, and may be simple, due 
to the ordinary pus-producing organisms, or specific, due to an 
infection with the gonococcus. A bacteriologic examination may 
be necessary to make the differential diagnosis. It may affect 
both male and female babies, but is more common in older 
children. 

The simple form is rarely severe. There is an invasion of 
the urethra from a balanitis, or a simple vulvovaginitis. In the 
male the infection is usually limited to the anterior urethra 
or the fossa navicularis. Combined with a balanitis the condi- 
tion is much more serious. There is pain on urination, the 
child shrinking from a voluntary passage of urine. The dis- 
charge is not very profuse or the duration of the inflammation 
very long. 

Treatment. — Hexamethylenamine by the mouth for the pur- 
pose of rendering the urine bland and unirritating, plenty of 
water drank, is about all that is needed. No local treatment is 
indicated as a rule. In obstinate cases it may be necessary to 
use an application of a 5 per cent argyrol solution. 

Gonorrheal Urethritis. — Unfortunately this form of infection 
is met oftener than is the general belief. It not only occurs 
among the poor, who live in unclean and. unhygienic surround- 
ings, but in the children of the well-to-do, who may employ a 
nurse who has the infection and is guilty of abnormal practices 
with the child, or may be transmitted through the medium of a 



496 THE DISEASES OF CHILDREN. 

towel or wash cloth. It occurs in boys most often between six 
and ten years of age. 

Diagnosis. — The only safe diagnosis is by examining the 
stained urethral discharge under the microscope. All urethral 
discharges should be examined in this way for diagnosis. 

Symptoms. — -A profuse, thick, creamy discharge from the 
urethra is present. There is pain on urinating, which may only 
be at the passage of the first few drops, or accompanied by 
severe tenesmus upon the completion of urination. The penis 
is usually swollen and tender. 

The chief complication to be feared is conjunctivitis because 
of the carelessness of the child. Orchitis, epididymitis and 
arthritis are uncommon in children. 

Treatment. — This does not differ in any essential from a 
specific urethritis in an adult, except that urethral irrigation 
is impracticable. Water, taken freely ; hexamethylenamine, gr. 
iii to V, in boy of six; santal, 5 min., will be found of service. 
A balanitis, complicating, also demands attention. 

In the specific cases the gonoeoccus vaccines may be used with 
benefit. 

Attendants should be warned against the possibility of infec- 
tion of the eyes by the discharge. 

VULVOVAGINITIS. 

This is an inflammation of the mucous membrane of the 
vulva, with secondary involvement of the urethra, vagina and 
possibly the cervix. It is simple or specific, the latter due to 
gonorrhea. 

Etiology. — The simple form is usually due to uncleanliness ; 
using the same napkin several times after it is wet before it is 
washed; pin- worms, or other infection from the rectum as the 
colon bacillus; the exanthemata; in institutions wKere the same 
towel is used by a number of children; trauma and masturbation. 

The specific form is due to an infection by the gonoeoccus, of 
Neisser, and in every case of vulval inflammation the discharge 
should be carefully stained and examined microscopically. It 
is usually conveyed by a towel or washcloth, infected by an 
adult, similarly affected. A mother may innocently have a 



DISEASES OF THE GENITOURINARY SYSTEM. 497 

latent gonorrhea, cervical or vaginal, and infect the child direct 
through the medium of the hands. I have had three cases re- 
cently. In one the father, in another the brother had an acute 
attack at the time and infected a towel, in the second the closest 
questioning has failed to reveal the source of contagion, though 
a colored nurse was strongly suspected. 

Symptoms. — The simple form may present few if any symp- 
toms, except a discharge. This may amount to very little, save 
a slight staining of the clothes. The vulva may be slightly 
congested, but usually this is not at all severe. 

Glandular enlargement in the groin may be noticed, with 
or without pain. 

In the gonorrheal form the process is rarely limited to the 
vulva, the invasion of the vagina and cervix being usual, as 
well as of the urethra, evidenced by tenesmus, frec[uent passage 
of urine or a desire to do so. There is a burning and itching. 
The discharge is quite thick and creamy, there is apt to be a 
sticking together of the labia, and an accumulation of pus in 
the ostium vagina. After a time there is no pain or discomfort, 
the only thing being the disagreeable discharge of pus. There 
usually is an enlargement, sometimes painful, of the inguinal 
glands, which may keep the child from walking or crawling. 

The specific form lasts longer than the simple, usually from 
four to six weeks. The last case I had under my observation 
was in the two-year-old child of a most intelligent and "faithful 
mother, with a persistence of the discharge for nearly seven 
wrecks. The examination of some of the secretion about the 
vulva is the only way that the progress of the case can be reck- 
oned. 

Complications. — Atresia of the vagina may occur: conjunc- 
tivitis, orchitis, epididymitis, inflammation of the glands of 
Bartholin, arthritis, inguinal adenitis, salpingitis, peritonitis. 

Prognosis. — This is good, but the duration is usually longer 
than in the simple form, averaging four weeks and often mucli 
longer. Diagnosis can only be made by a microscopic examina- 
tion of the pus and should be done early. 

Treatment. — The vulva and vagina should be carefully irri- 
gated with a 1 :5000 bichloride of mercury solution, followed 



498 THE DISEASES OF CHILDREN. 

by a solution of nitrate of silver, 2 per cent; Argyrol, 2 to 5 
per cent solution, can be used instead of the nitrate of silver. 
Extra precautions should be taken to limit .the possibility of 
an infection of the eyes, as this is apt to take place unless most 
careful precautions are taken. 

The inoculation treatment of specific vulvovaginitis has been 
used with some success.^ 

The patient's opsonic index is taken every other day accord- 
ing to Wright's method. At first the index should be compared 
with that of several healthy boys. 

The tolerance for the vaccine by the different patients varies, 
but an average of 1,000,000 is given and increased according 
to the index gonococcus. Local reaction usually takes place at 
the site of injection, as an indurated tender area. A general 
reaction is rarely seen. The injections are given eYery fifth 
or sixth day and should be guided by the index. The conclusions 
reached from observation of a large number of cases is that 
the vaccine treatment shortens the duration of an attack; that 
old strains are more effective than fresh ones; that the serum 
treatment is not to be recommended. 

The diet should be unirritating and nourishing; water taken 
freely between feedings. 

Because of the possibility of involvement of the scrotum and 
contents in male infants, the child should be kept in bed entirely 
during the acute stage. 

Treatment should be continued as long as there is any dis- 
charge, and discontinued only when no cocci are found on 
microscopic examination of the vulval secretion. 

CYSTITIS. 

This is an inflammation of the mucous membrane of the 
bladder. It rarely occurs as a primary condition but most fre- 
quently as a result of a calculus in the bladder, or secondary 
to a balanitis or urethritis, the latter usually of specific origin. 
It may be due to a direct invasion of the colon bacillus. 

Symptoms. — There is a distinct history of frequent and 
nearly alwaj^s of painful micturition, which has lasted a variable 
length of time. Mild cases may not complain of pain. There 



1 Churchill-Soper : Journal American Medical Association, vol. li, no. IG. 



DISEASES OF THE GENITOURINARY SYSTEM. 499 

may be pain in the perineum of the male and discomfort or 
pain in the lower portion of the abdomen in both sexes. 

The urine is acid if the colon bacillus is present, cloudy and 
contains epithelium and pus, probably a trace of albumin and 
many bacteria. Blood is present also, if there is a mixed 
infection. 

Prognosis. — Prompt recovery is the rule, except when the in- 
fecting organism is the gonococcus. 

Treatment. — Usually rest in bed, milk diet, copious drafts of 
water and hexamethylenamine, in from 3 to 5 grain doses, is 
all that is needed. In very acute cases, wdth painful urination, 
an anodyne may be needed. Bladder irrigation is not always 
necessary; when indicated a boracic acid solution, 1 or 2 ounces 
at a time, can be introduced and immediately withdrawn. 

UNDESCENDED TESTICLE. 

Cryptorchidism. 

During the early months of intrauterine life the testicles rest 
in the abdominal cavity, postperitoneally, just below the kid- 
neys. They pass downward and enter the scrotum, through 
the inguinal canal about the ninth month of intrauterine life. 

The testicle, one or both, fails to descend into the scrotum in 
the proportion of about 1 in 500 cases. It may be interrupted 
in its descent and remain in the cavity ; lodge at the internal 
ring; or it may lodge in the inguinal canal. 

Cases in w^hich the lodgement is in the cavity demand no inter- 
ference, but those which lodge at the internal ring or in the 
canal the indication for interference is present, as the organ 
may become injured ; inflammatory conditions of the cord and 
testicle are more apt to occur, and hernias prone to develop. 

For the relief of this condition Bevan ^ has suggested opera- 
tive procedures as follows : An incision 3 inches long over the 
inguinal canal dividing skin, fascia and external oblique 
aponeurosis. A pouch of peritoneum is found under the exter- 
nal obliciue extending from the abdominal peritoneum through 
the canal to the scrotum, even in cases in which the testicle 
has remained in the cavity. The pouch of peritoneum is opened, 



^ Keen's Surgery, vol. iv. 



500 THE DISEASES OF CHILDREN. 

cutting through the thin layers of cremasteric muscle and fascia 
and transversalis fascia. Transverse division of the vaginal 
process is made above the testicle and the upper end closed with 
catgnit. The lower end with a purse-string suture, thus making 
a tunica vaginalis for the testicle. The peritoneum is wiped 
from the cord with a sponge, and the fibrous strands in the 
cord torn with fingers or forceps, the cord being freed of every- 
thing but the vas and vessels. If the testicle will not reach 
to the bottom of the scrotum, it may be necessary to ligate and 
cut the spermatic artery and veins. Blunt dissection of the 
peritoneal pouch with the finger may be necessary to allow the 
testicle to be pushed in, where it is retained by a purse-string 
suture within the neck of the scrotum. The wound is then 
closed as in any hernia operation. 

The age for performance of this operation is between 5 and 
12 years of age. 



CHAPTER XXI. 

NUTEITIONAL DISORDERS. 

ATHREPSIA. 

Synonyms. — Malnutrition; marasmus ; inanition; ivasting dis- 
ease, infantile atrophij. 

Etiology. — This condition develops most frequently as a 
sequel to the acute gastrointestinal disorders, in which the di- 
gestive disturbance becomes chronic. 

It is characterized by atrophy of the tissues and a progressive 
loss in weight and strength. Heredity plays an important role 
in the etiology. Weak and delicate parents have poorly resisting 
offspring. 

Environment is a decided causative factor. Children in over- 
crowded tenement districts, with badly ventilated sleeping quar- 
ters, who get but little fresh air and have poorly prepared food, 
are liable to develop this condition. 

The most important cause is the food. The food itself may 
be all right but its mode of preparation, method of administra- 
tion and quantity may result in an intestinal intoxication with 
resultant malnutrition. 

It usually begins after the sixth month of life, and reaches 
its height before the second year, if the child survives this long. 
It is rarely seen among children who are breast fed. 

"Hospitalism" is sometimes the cause. For some unknown 
reason a child may not do well in an orphan asylum, and if its 
surroundings and environment are changed without change of 
diet they do well. 

Pathology. — There is no distinct pathology to this condition ; 
coincident with the general atrophy and wasting of the tissues 
there is an atrophy of the glandular structure of the digestive 
tract. There is a condition of li/mpliatism, an enlargement of 
all the lymph nodes of the body, especially of the mesentery, soli- 
tary glands of the intestines and the bronchial glands. 

501 



502 THE DISEASES OF CHILDREN. 

The subcutaneous fat is absorbed and the skin of the body 
is wrinkled and lies in folds. As the condition progresses, the 
skin of the face becomes tightly drawn over the bones and the 
child assumes the old-man appearance which is so characteristic. 
Hemorrhages may occur in the skin or the mucous membranes, 
especially of the intestines. 

Symptoms. — In every case of acute gastrointestinal disorder 
the possibility of its terminating in a condition of athrepsia 
should be borne in mind, and the child put on a gaining diet at 
the first possible moment, without overtaxing the digestive capac- 
ity. The child's weight is the best guide as to the importance 
of this. A progressive loss in weight each week is an indication 
for increased watchfulness. 

Athrepsia is essentially an insidious condition, reaching an 
alarming proportion in a period extending over several months. 

There is a progressive loss in weight; the subcutaneous fat 
disappears and the skin lies in folds; it is harsh and dry to 
the touch ; the abdomen soon becomes distended from accumu- 
lation of gas in the stomach and intestines, principally in the 
colon. It is restless and irritable, crying or whining con- 
stantly; the temperature is apt to be subnormal, with occasional 
rise, from an intercurrent intestinal toxemia or indigestion. 

The bowels are apt to be constipated; but thin mucus move- 
ments are occasionally seen. It is rare that two actions passed 
are of the same color or consistence. They are more often green 
than of the normal color, and frequently contain undigested 
particles of food, and are universally of a foul, putrefactive odor. 

Because of the irritating character of the discharges the skin 
of the buttocks develops an intertrigo; it is red, thickened, and 
may become moist if it breaks down. 

Dentition is delayed and a stomatitis is apt to occur; the 
tongue is usually dry, cracks develop at the corners of the mouth. 

The child will usually act as if famished, and will take eagerly 
any food or water which is given. Vomiting is frequently pres- 
ent, chiefly owing to the rapidity with which food is taken and 
the over-distending of the stomach. Dilatation of this organ 
quite regularly results. 

Diagnosis. — The differentiation of athrepsia from the less 



NUTRITIONAL DISORDERS. 503 

serious forms of malnutrition is difficult, as there is no fine-cut 
line of difference. It must be differentiated from tuberculosis 
and congenital syphilis. In the former there is apt to be a 
rise in temperature, probably with signs in the chest if of that 
form. The localization of tuberculosis in any organ or struc- 
ture should make the diagnosis easier. The enlargement of the 
lymph nodes in both forms makes this occurrence of no assist- 
ance as a diagnostic sign. 

In congenital syphilis the changes in the skin and mucous 
membranes, snuffles, history and, as a rule, earlier development 
of symptoms assist in the differentiation. 

Prognosis. — The condition is invariably a grave one, espe- 
cially in the severer forms of the trouble. Where hospitalism 
is a feature the results are universally bad. 

The condition is progressive and a fatal result almost 
inevitable. 

Treatment. — A most careful inquiry must be made into the 
routine of the child's life, its feeding from birth, with details 
of the various changes in the diet, and a record made of the 
character, of preparation and quantity of the food given. This 
is most essential as the diet is so often at fault primarily. 

If its environment and surroundings are at fault these must 
be changed. If hospitalism is present, endeavor to have the 
child placed in a private family or isolated in larger quarters 
with more air available. A change of climate is often of great 
benefit in children in private homes. 

Regular bathing, bran baths, salt rubs, olive-oil rubs, after 
the water baths ; careful attention to the skin of the buttocks, 
and to the napkins and feeding apparatus; plenty of out-of-door 
air ; attention to the mouth, with frequent use of a boracic acid 
mouth wash. The most important consideration is of the food, 
which must be regulated as soon as the gastrointestinal tract 
has been placed in as normal a condition as possible. This is 
brought about by giving an initial dose of calomel, gr. i in V^ 
gr. doses, repeated at half -hour intervals, and followed by a 
dose of oil. 

If on the breast the milk must be examined and the deficien- 
cies in it corrected by artificial feeding, or a suitable wet-nurse. 



504 THE DISEASES OF CHILDREN. 

if possible. A preliminary exaraination of the milk of the wet- 
nurse must be made. 

If on a modified milk, this should be withdrawn until after 
the preliminary cleaning out of the intestinal tract, a dextrin- 
ized barley water being temporarily given. 

A modified milk, low in fat percentage, should be given at 
first, and in small quantities at two-hour intervals. As the 
child evidences an ability to take care of the food it can be 
increased both in strength and quantity. The stools must be 
closely watched. 

The importance of obtaining a certified milk, or milk of equal 
cleanliness, should be emphasized. Whey is a valuable food 
to be used during the period of getting the child on to a gain- 
ing diet. 

A prescription as follows can be used to advantage at first : 
Fat 0.5 to 1.0, sugar 6.0, and proteid 0.5 to 1.0, the proteid 
increased slightly more rapidly than the fat as the child shows 
evidence of ability to care for it. 

The tendency is to give these babies cod liver oil or olive 
oil, to bring up the fat deposit in the system, but it should be 
given with great caution. Fats are poorly taken care of in 
the intestine, and the intestine can be easily overwhelmed, with 
these, if given in addition to the regular diet. Lavage can be 
used in the obstinate vomiting cases, and gavage in those cases 
jn which vomiting continues in spite of stomach washing. 

The advantage of using partially or completely peptonized 
milk in the beginning of these cases should be borne in mind, 
but should not be too long continued. 

Tonics have their place in the treatment of this condition; 
as minute doses of strychnia, iron, diastatic agents, as pancrea- 
tine, etc., and stimulants, in certain cases may be indicated. 

SCORBUTUS. 

Synonyms. — Infantile scurvy; Barlow's Disease. 

This is a constitutional nutritional disease due to prolonged 
error in diet. Hemorrhages are its chief manifestation, and 
these may be in the joints, under the periosteum or from the 
mucous and serous membranes, and in the tissues. 

Etiology. — This is particularly a disease of infancy, being 



NUTRITIONAL DISORDERS. 505 

seen most often before the second year of age, rarely before the 
fonrth month. The diet is the chief cause, viz.. prolonged use 
of one of the artificial foods, condensed milk, cow's milk in 
improper modifications, which usually has been Pasteurized or 
sterilized. Isolated cases have been reported as developing in 
children who have been on breast milk exclusively. These have 
been rare, however. The continued use of any food which 
lacks the vital quality of freshness, will cause scurvy. 

Pathology. — The chief changes are in the blood vessels which 
permit of the escape of blood into the joints or tissues, or a 
changed blood which can escape from more or less normal blood 
vessels. The chief hemorrhages seen are under the periosteum 
of the long bones, principally of the lower extremities, in the 
joints, from the mucous membranes, and in the subcutaneous 
tissues. The bones of the arms are less often affected, but 
hemorrhages do occur at the ends of the ribs and on the scapula 
and sternum. 

Numerous ecchymotic spots appear in the skin of the body. 
The mucous membrane around the teeth and of the gums, 
becomes spongy- and bleed if touched. The teeth may become 
loosened. 

Symptoms. — -The child usually gives a history of doing badly 
for several weeks, is pale and anemic and more restless than 
usual. Suddenly, if it has been walking, it refuses to stand, 
and cries when handled. The joints become swollen and very 
tender, and there may be pain when the child is entirely cpiiet, 
but this is not usually the case. Examination of the legs reveals 
swellings along the shaft of the long bones and near the epiph- 
yses, and the joints are swollen, usually without redness. 

The skin may show a number of hemorrhagic spots, like 
bruises, some large, or there may be a number of petechial 
spots scattered over the body. Characteristic changes occur in 
the mouth. The gums are spongy and usually extend some dis- 
tance up on the teeth, and they bleed on the slightest touch. 
The gums may not break down, if no teeth <u*e present, but the 
mucous membrane over them usually shows a number of small 
hemorrhagic areas. 

Melena may be present and blood in the urine is not uncom- 



506 THE DISEASES OF CHILDREN. 

mon, with blood casts and albumin present also. A single or 
double exophthalmos due to blood in the orbit may be present, 
but this is not at all a constant symptom. A subconjunctival 
hemorrhage sometimes occurs. Discoloration of the skin around 
the eye, a so-called ''black eye," is often present, especially 
when there is an exophthalmos. Hematuria is not infrequently 
present. In regard to the blood count in scurvy. Da Costa 
reports, as a result of examination of seven cases, an average 
hemoglobin percentage of 43 per cent, an average of red cells 
of 3,527,000, the average leucocytes of 15,500. In only one 
of the seven cases was there a leucocytosis. 

Diagnosis. — The chief trouble to be diagnosed from is rheu- 
matism. I have seen three such cases, each had been vigorously 
treated for rheumatism, and each presented the classical symp- 
toms of scurvy. If the chief pathological conditions of scurvy 
are borne in mind the diagnosis is plain, as a rule, viz., hemor- 
rhages under the periosteum and in the joints, and the typical 
changes in the gums. Owing to the forced immobility from 
the pain in the joints the legs have the appearance of being 
partially or completely paralyzed. The muscles are tense, to 
protect the leg, and have none of the true appearance of a 
paralysis. Occasionally there is a rise of temperature, but it is 
irregular and rarely high. Among the other conditions which 
may be mistaken for scurvy are as follows; periosteitis, osteo- 
myelitis, hip disease, injury, difficult dentition, infantile 
paralysis. 

Prognosis. — This is universally good if the condition is recog- 
nized early and appropriate treatment begun. Even the hemor- 
rhages causing the exophthalmos are quickly absorbed. Delay 
in the diagnosis prolongs convalescence proportionately long. 

Treatment. — This is essentially one of diet, no medication 
being required. Inquiry should be made in detail in regard 
to the feeding, and it should be taken off all proprietary foods, 
and put on fresh, unsterilized and unpasteurized cow's milk at 
once. If the child is under one year, the milk should be so 
modified that the fat and proteid contents are not too high; 
if over one year of age a 4 per cent milk can usuallj^ be easily 
taken care of. 



NUTRITIONAL DISORDERS. 507 

In addition to the milk the child should be given strained 
orange juice, which is practically a specific, at first half an 
ounce twice daily, between feedings, gradually increased to 
li/o or 2 ounces. One or two feedings a day of an animal broth, 
or the expressed juice of beef, will be found most beneficial, 
and one feeding of a small, baked Irish potato daily. One or 
two tablespoonfuls of the beef juice can be given alone or as 
gravy over the potato. 

Careful regulation of the hygienic conditions should be made, 
the child kept in a bright, airy room, with plenty of sunshine. 
It should be kept quiet and not handled more than necessary 
to keep it clean, and the improvement will be decided in the 
course of three or four days. 

Medication is, as a rule, not needed, except it be to combat 
the anemia which is present in nearly all cases, especially if of 
long standing and it does not respond to the dietetic treatment. 

Iron in some form Avill be well borne : 

I^ Tinct. ferri cliloridi 5ii 

Glycerini 5SS 

Aquae destillatse q.s 5!! 

M. ft. Sol. One teaspoonful after eating, three times a day. 

The prevention of scurvy is of great importance. The diet of 
every artificially-fed infant should receive careful supervision, 
proprietary foods not used, and the progress report regiilarly 
sent in for the guidance of the physician. 

RACHITIS. 

Synonym. — Ficl-efs. 

This is a constitutional disease or disorder of nutrition in 
which the most striking changes are in the bones, the principal 
site being the epiphyses, though more or less marked changes 
occur in every other organ and tissue of the body. 

Etiology. — Bad hygienic surroundings and unsuitable food 
are the principal causes. Infants who are breast fed well into 
their second year, or who are getting a breast milk below stand- 
ard in quantity and quality, or the artificially fed in wliom the 
proprietary foods or condensed milk are given to practically 
the exclusion of fresh food, are prone to develop rickets. From 



508 THE DISEASES OF CHILDREN. 

this we would scarcely expect to see a case before the sixth 
month, but cases of fetal rickets have been reported. In con- 
densed milk, and in some of the proprietary foods also, the chief 
element lacking is the fat, as in any dilution recommended the 
fat content is low. 

A history may be obtained of a previous exhausting disease, 
as a prolonged gastrointestinal disturbance or the exanthemata, 
a bronchitis of some weeks duration, always, however, in con- 
nection with some irregularity in diet or a failure to give the 
child a well-balanced ration, which is meeting the needs of its 
nutrition. 

Rickets is more frequently found in the colored race than 
in any other, next in frequency perhaps in Italians. In both 
these races over-crowding, unhygienic surroundings and im- 
proper food are present. 

Pathology. — All of the tissues of the body share in the nutri- 
tional changes found, but because of the prominence of the bony 
changes attention is chiefly focused on them. The bony changes 
occur in the' centers of ossification and consist in the excessive 
deposit of cartilage at these points. In the long bones it is at 
the epiphyses, in the flat bones, especially of the skull, it is in 
the center. Owing to the deficiency in the lime salts in the carti- 
lage cells these fail to ossify, and all the bones are soft and more 
or less flexible; because of this condition the fairly character- 
istic bony deformities of rachitis take place. Craniotabes is a 
characteristic condition, being a softened area to the sides 
of the occipital protuberance, which can be very easily demon- 
strated. 

There is a congestion or hyperplasia of the periosteum at the 
ossification centers. It is easily removed from the bone. Micro- 
scopically a marked increase in the new cartilage cells is seen, 
and an increased vascularity of the proliferating zone. 

Anemia is always present, the hemoglobin is relatively low. 
Morse's^ cases averaged 63 per cent with a color index of 0.7. 
The red cells in his cases averaged over 4,500,000. 

Leucocytosis is present in many cases, but not in all by any 
means. 



1 Boston City Hospital Rep., 1897. 



XUTRITIOXAL DISORDERS. 509 

The muscles are flabby, and the ligaments Aveak and easily 
stretched, the heart is weak and irritable. 

Bronchitis and pneumonia are frequent complications, there 
seeming to be an almost constant state of passive congestion of 
the mucous membranes. 

There is an enlargement of both the liver and the spleen, espe- 
cially the latter. The spleen can quite easily be palpated below 
the costal margin. 

Symptoms. — Focal. — The head of the rachitic child is en- 
larged, the bitemporal and biparietal diameters are increased. 
Bosses develop at the centers of ossification, chiefly of the parie- 
tal and the occipital bones. The forehead is high, and the 
fontanelles are both late in closing. Frequently the sutures 
are found ununited. 

The rachitic rosary is a fairly constant symptom. This is 
an enlargement of the ribs at their costal margin and gives the 
impression of a string of beads. If these enlargements are of 
some size their under surfaces will make indentations on the 
lungs. As a result of the softening of the costal cartilage the 
atmospheric pressure pushes in this portion of the chest wall, 
causing the sternum to be more prominent. This deformity is 
called a pigeon breast, and is fairly characteristic. 

The ends of the long bones show an enlargement, the epiph- 
yses at the wrist being specially large. 

If the child is walking, the weight of the superimposed body 
causes a bend in the femur and bones of the leg, as well as an 
exaggeration of the curves of the spine. A lateral curvature 
not unusually develops. Genuvalgum, a knock-knee, and genu- 
varum, bow-legs, are common deformities. An anterior curva- 
ture of the tibiffi is often present. This is probably, in part, 
at least, due to the child sitting in a chair with its feet extend- 
ing beyond the anterior edge, the weight of the foot causing 
the bend in the tibia. 

At this stage of bony formation, softening of the pelvic bones 
may result, in female children, in a flattening of the pelvis, caus- 
ing the flat rachitic pelvis which results in a dystocia in the 
child-bearing period. 

Dentition is delaved and often difficult. After the teeth are 



510 THE DISEASES OF CHILDREN. 

cut they are soft and decay early, the front teeth often crnm- 
bling away. 

Systemic Symptoms. — An anemia appears early and is fre- 
quently quite pronounced. 

Owing to the loss of tone of the musculature of the stomach 
and intestines these organs become distended, and the child pre- 
sents a ''pot belly." Attacks of gastroenteritis are frequent. 
Constipation is the rule. These conditions are chiefly due to 
the child eating more than it can digest and assimilate. 

Head sweating is an early and prominent symptom, and when 
present should cause the physician to be suspicious at once. 
The child's pillow will be wet whenever it lies down to take its 
nourishment or to sleep, and its hair quite wet, with beads of 
perspiration on its forehead and neck, and this in spite of the 
temperature of the room. 

It is cross and irritable, and if muscle tenderness is present 
it cries if it is handled or moved. 

It is very restless and sleep is greatly disturbed ; it will cry 
out in its sleep very frequently. It is often wakened at night, 
with a spasmodic condition of the larynx, causing a peculiar 
crowing-like sound. This is laryngismus stridulus and is a 
fairly constant diagnostic sign. 

The child is backward in walking, due to the deficient muscular 
power, the muscles being soft and flabby. The association of 
adenoids and rachitis is not infrequent, the child being a mouth 
breather in consequence. 

Late in the disease there is a temperature of from one to three 
degrees, with acceleration of the pulse rate. This is due to some 
intercurrent affection, particularly bronchitis or pneumonia, or 
gastrointestinal trouble. 

Prognosis. — Rickets is a chronic affection, usually running 
its course in about two years, if upon the proper diet or treat- 
ment. Because of their weakened state and lack of resistance 
rachitic children are more likely to develop the acute exanthe- 
mata, diphtheria, whooping-cough, pulmonary diseases, etc. 

Prognosis is worse in diseases of this nature in the rachitic. 
There may be a gradual absorption of some of the bony deposit 
at the epiphyses and bosses, but the deformities do not disap- 



NUTRITIONAL DISORDERS. 511 

pear. The flat rachitic pelvis, the genuvarum and valgum, the 
kyphosis, remain during the life of the child. 

Diagnosis. — In every child not doing well rickets should be 
borne in mind, as its earliest symptoms are vague and might go 
unrecognized. But if the principal symptoms are remembered 
the diagnosis should be easy, viz., head sweating, rachitic rosary, 
enlargement of the epiphyses, craniotabes, constipation, delayed 
dentition, restlessness at night, anemia, larj^ngismus stridulus 
and enlarged abdomen. 

Treatment. — The principal indication is to learn the cause, 
if possible, and remedy it. If it is the feeding which is at 
fault it must be carefully regulated, fresh and properly modi- 
fied milk given; proprietarj^ foods must be withdrawn; scraped 
beef is of great assistance in building up these cases. If the 
quality of the breast milk is found at fault, with ample quantity, 
the nursings should be shorter and the child given a small arti- 
ficial feeding after nursing of a modified milk with formula 
suited to its needs. If on modified milk the same formula may 
be kept up for too long a period, and be unequal to the demands 
of nutrition when teething has begun. This is seen very often. 

If on a mixed diet, it may be found the child makes one or 
two meals on cereals, heavily loaded with sugar, di'inks but 
little milk, rarely tastes meat, eats much potato and bread. 
The proteid and fat in its diet is greath' lacking, and this must 
be regulated by the use of inilk, cream, scraped beef and beef 
juice, animal broths, eggs, and of butter in the older children. 

Regulation of the child's surroundings, cleanliness and daily 
routine of living is of vast importance, if in the crowded dis- 
tricts of a city they can't get the fresh air so necessary to their 
vitality. These children need plenty of air and out-door sun- 
shine. Fresh air must be in the sleeping rooms also. The daily 
bath is very necessary, which should be followed by a cool sponge, 
especially over the chest and back, for the purpose of inuring 
them to the changes in the atmosphere. A sea salt bath is ben- 
eficial. 

Medicinal. — Cod liver oil. in these cases, is of great benefit, 
and it can be used either plain or in an emulsion. 

The oil shoukl be looked upon as a food as well as medicine, 



512 THE DISEASES OF CHILDREN. 

and its effects closely watched. If it is regurgitated or if it is 
passed unchanged in the stools the dose must be lessened or 
it should be temporarily withdrawn. If used plain it can be 
given in gradually increasing doses, until the maximum dose is 
reached, from 5 drops to 1 teaspoonful, after meals. None of 
the so-called extractives of cod liver oil are satisfactory. 

Owing to the lime needed in bony formation, the combina- 
tions of the hyphophosphites of lime with the emulsion of oil 
are of benefit. 

Considerable discussion has been indulged in by the pediat- 
rists on the value of phosphorus in rickets. In my experience 
it has been of unquestioned benefit. It can be given either as 
the officinal oil of phosphorus, with olive oil or cod liver oil, in 
dose of 1/200 to 1/100 grain, three times a day. Thompson's 
solution containing 1/20 grain to the drachm can be used also. 

Iron in some form is nearly always indicated sooner or later 
to combat the tendency to anemia, and can be given in the form 
of the hypophosphite (ferri hypophosphis, U. S.), 1 to 2 grains, 
in the form of a syrup ; the tincture of the chloride of iron, with 
glycerine; or diastiron in drachm doses. These should be given 
after eating. 

For excessive head sweating atropia sulphate in 1/800 grain 
doses can be given at bed time. 

Other conditions should be treated as they arise, pulmonary, 
dietetic and gastrointestinal complications. 

Deformities should be appropriately handled. Spinal curva- 
tures by decubitus ; tendency to bow-legs or knock-knee by keep- 
ing the child off' its feet and off the floor. Deformities of the 
pelvis cannot be prevented except as they are arrested by the 
general improvement from appropriate treatment of the general 
underlying condition. Tendency to formation of spinal curva- 
tures can be combated by recumbency or the use of a spinal 
frame to which the child is strapped for transporting. 



CHAPTER XXII. 

DISEASES OF THE NERVOUS SYSTEM. 

GENERAL CONSIDERATIONS. 

The nervous system of the new-born child differs from the 
older child or adult, in that it is more immature in develop- 
ment than any of the rest of its tissues. During the first five to 
seven years of its life it develops more rapidly than the rest 
of its body, especially as to its function. Early, the brain is 
unstable, there is but little inhibition of nerve force or energy, 
and there is also no development of the centers controlling the 
involuntary muscles, especially the sphincters. The nerve cen- 
ters of an infant or child react to reflex stimulation much more 
readily than when the nervous system is mature. This accounts 
for the frequency of convulsions in the infant. The nervous 
system of the child is more susceptible to depressing influences 
of impoverished blood than the adults, this being specially true 
of girls, up to the time of puberty they are more prone to de- 
velop serious functional and organic nervous troubles. 

The question of heredity, so little understood, is one to be 
seriously thought of in the diseases of the nervous system. 

Nervous diseases are either functional or organic. Among 
the former are chorea, convulsions of reflex origin, neurasthenia, 
hysteria, in these troubles there being no pathological condition 
responsible for the disease. In the organic form there are path- 
ologic changes in the cells and nerve tissue. 

DIAGNOSTIC METHODS. 

With a nervous disorder suspected, a careful, systematic exam- 
ination must be made. In conditions such as chorea or hysteria, 
if the child can be watched at play, or while recumbent, entirely 
casually, without the child's attention being called to the fact 
that it is being watched, a much better idea of the symptoms 

513 



514 THE DISEASES OF CHILDREN. 

can be had. If the child is under constraint with a conscious- 
ness of being watched, the symptoms will be modified. 

It may be necessary to have the child walk, if possible, to 
learn whether there are any paralyses, the character of the gait, 
whether there is a spastic condition of the muscles of the ex- 
tremities, atrophies or deformities. The child should be made 
to squeeze one or two fingers of the examiner to obtain the con- 
tractile power of these muscles, to hold the hand out straight, 
lightly touching the open palm of the examiner to obtain any 
fibrillary twitchings of the muscles. The examination should 
not be concluded without the child is stripped and all parts of 
its body examined, especially the spine. 

The reflexes must be tested, the most important being the fol- 
lowing : 

The Knee Jerk. — In the very young this is difficult to ob- 
tain, in older children it can be elicited. The legs are allowed 
to hang over the edge of chair or .table ancl the patellar tendon 
struck gently with the end of the finger, or percussion hammer, 
as in percussion of the chest. The child's attention is diverted 
during this manipulation by having it clench its hands tightly 
together and pull hard. 

The Biceps Jerk. — The child's arm is held flexed and relaxed 
w^itli the thumb of the hand supporting the arm, held along the 
biceps. With the second finger or with a percussion hammer 
the biceps is struck a gentle blow direct, or the thumb is per- 
cussed and the muscle can be felt to contract. 

Cremasteric Reflex. — By stroking the inner aspect of the 
thigh with the finger the muscle of the scrotum contracts, rais- 
ing the testicles. 

Sensation. — The examination for sensation should include the 
examination for the presence or absence of sensation of pain and 
the period of time which elapses before the sensation is received. 
A pin, camel-hair brush, hot and cold substances, are needed 
to elicit this symptom. The child's expression should be closely 
watched for the evidence of the reception of sensory impres- 
sions. This symptom is of importance in spinal cord lesions. 
The fontanelles should be examined and note made if they are 
open, sunken or bulging and tense. 



DISEASES OP THE NERVOUS SYSTEM. 515 

Babinski's Reflex. — Irritation of the soles of the feet causes 
a dorsi-flexion of the great toe toward the dorsum of the foot, 
while the other four toes are flexed toward the sole of the foot. 

Kernig's Sign. — In 1882 Kernig described a condition which 
is more or less pathognomonic of meningitis. It consists in 
the inability to extend the leg fully on the thigh, the thigh being 
flexed at a right angle with the trunk. It is involuntary and is 
not accompanied by or due to pain. Kernig considers the sign 
positive when the angle is 135° ; others place it at 120° or even 
115°. 

]\Iorse concludes it is almost never found in infancy, either 
in health or disease, except in meningitis. It occurs with equal 
frequency at all stages of the disease. It is of no importance 
as a diagnostic sign between the tuberculous and cerebrospinal 
forms. 

The vision of the child should be tested. The mother is 
often deceived as to this point. A lighted taper or bright ob- 
ject moved in front of the eyes will cause them to follow the 
object back and forth. The pupils are examined to ascertain 
if they are equal, and if they contract promptly to light stimu- 
lation. Constant movement of the eye, nystagmus, is a very 
striking symptom. 

The hearing should be carefully tested by a sudden sound, as 
a whistle, or clapping the hands, being made behind the child. 

Squire's Sign. — The child lying on its back, the head is 
grasped and slo^^ly extended as far as possible. The pupils 
dilate during this and contract as the head is flexed. 

Electrical Examinations. — As an aid to diagnosis electricity 
is of great value. The nerves of the new-born respond onh^ to 
strong currents. Children are easily frightened by this test. 

The examination is begun with the faradic current, one pole 
on the muscle to be examined, the other on the chest, and only 
a current strong enough to produce a contraction is used. In 
inflammatory and degenerative conditions of the nerves, both the 
nerves and muscles show a diminution in the faradic response, 
but the muscles may continue to partially respond to the gal- 
vanic current, and these changes are called the reaction of de- 
generation. 



516 THE DISEASES OP CHILDREN. 

Electricity is also of value in differeutiating cerebral disease 
and diseases of the spinal cord and peripheral nerves. 

Lumbar Puncture. — As a method of diagnosis this procedure 
is of value, and is performed as follows : The child can lie upon 
its side, with head and shoulders elevated, and slightly bent 
forward, putting the tissues of the back on a stretch. The latter 
position favors the flow of fluid. The skin is thoroughly ster- 
ilized with soap and water and alcohol. A general anesthetic 
can be administered if desired, or local anesthesia with cocaine, 
Sehleich's solution or kelene. 

The puncture is made with an ordinary aspirating platinum- 
needle or small trocar, 9 or 10 cm. long, and 1 mm. in diameter, 
w^hich is sterilized by boiling 10 minutes. The puncture does 
not hurt much more than the introduction of the cocaine. 

The space between the third and fourth, or fourth and fifth, 
lumbar vertebrge is selected, as at this point the cord is not 
injured. The iliac crests are on a level with the fourth spinous 
process, and the needle with one motion plunged to the inter- 
vertebral cartilage 1 cm. to one side of the median line. If the 
cartilage is located with certainty the canal is entered with the 
point of the needle, and to a depth of about 3 or 4 cm. The 
cerebrospinal fluid at once escapes, at the rate of 1 or 2 drops 
a second, or even slower in some cases. To make a thorough 
examination of the fluid 4 cc. to 5 cc. should be obtained, and 
should be dropped directly into the capillary tube of the centri- 
fuge, after obtaining enough for cover-slip examination. 

The normal cerebrospinal fluid is clear, and of a gravity of 
1003, and contains a trace of albumin and is practically free 
from cells. In inflammation of the meninges the fluid is cloudy 
from an exudation of cells, dependent of course upon the char- 
acter of the exudate. In the tubercular form there is very 
little cellular exudate. 

Cover-glass preparations (from the fresh fluid as it is with- 
drawn or from the sediment in the capillary tube, the latter 
preferable) are stained with Wright's stain. Tothe's method 
of diagnosis has been given. 

In tuhercular meningitis the fluid appears clear, as a rule, ex- 
cept on close examination. If the test tube containing the 



DISEASES OF THE NERVOUS SYSTEM. 



517 




Fig. 83. — Locating the inter-vertebral space for lumbar puncture. Middle fingers 
on crest of ilium, index finger one-half inch above this line. 




Fig. 84. — Lumbar puncture. Nurse holding sterile bottle to catch fluid. 



518 THE DISEASES OF CHILDREN. 

fluid is allowed to stand upright in an ice box for 24 hours a 
precipitate or coagulum, wedge or funnel-shaped forms, which 
is fairly characteristic of this type. 

If many polynuclear leucocytes are found in the sediment 
it is not the tubercular form. The large and small lymphocytes 
in the sediment indicate tubercular meningitis. The inocula- 
tion of guinea-pigs may be necessary to clear up the diagnosis 
of the tubercular form. 

In the suppurative form of meningitis the fluid is very cloudy 
and contains pus cells, and a large number of leucocytes. 

In epidemic cerebrospinal meningitis the same procedures 
are gone through with and the sediment examined for the diplo- 
coccus intracellularis. 

FUNCTIONAL DISEASES OF THE NERVOUS SYSTEM. 

CONVULSIONS. 

Infantile Eclampsia. 

This is a symptom and not a disease, and consists in a motor 
discharge, resulting from a cerebral irritation, evidenced by con- 
clusive movements or contractures of the muscles of one or more 
parts of the body. 

Etiology. — The nervous system of the child is so subject to 
reflex stimuli, and the inhibitory power of the brain is so 
poorly developed, that convulsions occur with comparative fre- 
quency. Among these stimuli are the toxins generated at the 
onset or during the exanthemata, toxins generated in the gas- 
trointestinal tract, rachitis, phimosis, dentition and a host of 
other conditions may, reflexly, cause convulsions. When oc- 
curring during the first week or two of life the convulsion may 
be due to pressure on the brain from within, from a hemor- 
rhage ; later to an organic disease of the brain, as an abscess, 
hemorrhage, meningitis, etc. ; they may be due to an hereditary 
condition, epilepsy, or may be traumatic. Convulsions are much 
more frequent during the first two years of life. 

Symptoms. — The convulsions may be the first evidence of 
trouble, or it may present many preliminary symptoms. No 
two are alike, yet there are certain symptoms common to most. 



DISEASES OF THE NERVOUS SYSTEM. 519 

The seizure is usually ushered in by a preliminary cry, the 
muscles of the face contract and the child at once develops tonic 
and then clonic convulsions of one or more parts or of the entire 
body. The head is thrown backward, and the back may be 
arched, the weight of the body supported by the back of the head 
and the heels, the position of opisthotonos. The eyes are 
rolled upward, and the pupils are dilated and fixed; there is a 
snoring respiration, spasmodic in character, due to the contrac- 
tions of the diaphragm, and the face becomes a dusky color. 
If the convulsion lasts some time, deep asphyxia may be present. 
The tongTie may be bitten in older children if protruded be- 
tween the teeth. Clonic or slight convulsions follow the tetanic 
ones, and when quiet the child falls into a sleep or a state of 
coma, to waken rational or to go without regaining conscious- 
ness into another more or less severe spasm. The urine and 
feces may be passed involuntarily. 

Prognosis. — A single convulsion may give rise to no sequelse, 
but repeated ones are serious, as they may be the starting point 
of severe organic lesion of the brain, resulting in epilepsy. The 
prognosis depends very largely upon the cause of the condition. 
If due to the exanthemata there may be no recurrence, as early 
elimination removes the disturbing element. 

Treatment. — The convulsive seizure must be controlled, and 
this can probably best be done by the inhalation of chloroform. 
The first thought of the mother and laity is to place the child 
in hot water, and much harm has undoubtedly been done by 
this procedure. The child is exposed unduly, and frequently 
burned, by too hot water being used, in the excitement. Ju- 
diciously applied the relaxing effect of a plain full bath or of a 
mustard bath may be A^ery pronounced. 

The next indication is to remove the cause if possible. Be- 
cause of the frequency of toxins from the intestine being the 
cause, as soon as the child can swallow, a dose of castor oil should 
be administered to completely empty the intestinal canal. A 
colon irrigation should be given early. This may be cool if there 
is much fever. Kest and quiet are most essential. To prevent 
a recurrence the child is given one of the bromides, along or 
with chloral hydrate (bromide of strontiuni; gr, v, with chloral, 



520 THE DISEASES OF CHILDREN. 

gr. iv), over a period of several days or a week or more. If 
unable to swallow the first dose may be given by the rectum 
following the irrigation and emptying of the bowel. The gen- 
eral treatment of the underlying physical condition is important. 
If there is rachitis it must be given appropriate treatment, and 
child kept closely under observation. If of school age, it should 
be kept away from school for an indefinite time. 

CHOREA. 

Varieties. — Several varieties of this disease are recognized 
under the generic term of choreiform diseases, the variety, how- 
ever, usually indicated by the unqualified term chorea, is chorea 
mirror, or acute chorea. 

The other varieties are chorea major, Huntington^ s or hered- 
itary chorea, habit chorea, electric chorea. 

CHOREA MINOR. 

Synonyms. — St. Vitus' dance; Sydenham's chorea; acute 
chorea. 

Definition. — A neurosis, occurring almost exclusively in chil- 
dren before puberty, characterized by involuntary movements 
and twitchings of muscles or groups of muscles of the body. 

Etiology. — There is unquestionably a close relationship be- 
tween this disease, rheumatism and tonsillitis. Among the 
other diseases which bear a causal relationship are the exanthe- 
mata, tonsillitis, diphtheria. There may not be a distinct his- 
tory of rheumatism, but of vague pains in the joints, which 
without close questioning would probably not be mentioned in 
the history. The occurrence of heart lesions in chorea, reported 
by many observers, is a further confirmation of this theory. 

The majority of cases occur between the ages of 10 and 15 
years. Girls, about the age of puberty, are more prone to de- 
velop it. Unhygienic surroundings w^ith poor food, which leads 
to intestinal intoxication, are predisposing causes frequently 
seen. Crowding at school, both as to the number in the classes 
and the amount of work accomplished, may act as causes. He- 
redity is also a factor. Either direct history of chorea in the 
mother or a mother of an excessively nervous temperament may 



DISEASES OF THE NERVOUS SYSTEM. 521 

be elicited. Dr. Weir Mitchell has claimed that a larger num- 
ber of cases occur in the spring of the year. A sudden shock 
to the child, as a severe fright, may induce an attack. 

Pathology. — No characteristic or constant change has been 
found in the nervous system in those cases which have been exam- 
ined at autopsy. Among the changes reported by different 
observers are the following, vascular changes, as the result of 
an infection; cortical changes of an indefinite kind, chiefly a 
calcification of the ganglion cells (Golgi) ; connective tissue in 
the spinal cord and nerve centers (Garrod) ; calcification of 
ganglion cells (Golgi) ; hyperemia of the brain and cord, and 
simple changes in the serous membranes. Tonsillitis and endo- 
carditis may be found. 

Symptoms. — In the mild form of chorea there may be few 
or no prodromal symptoms, perhaps a short period of irritability 
or depression, in which the child cries easily and without provo- 
cation, followed shortly by a contraction or twitching of a group 
of muscles. This may evidence itself by a spasmodic winking of 
the eyes or jerking of the facial muscles, usually of one side or a 
jerking or raising of the arm or shoulder. The muscles of the 
hands soon become involved and the child drops articles with- 
out cause, it appears awkward at the table and handles 
eating utensils clumsily. If the lower extremities are involved 
it may walk jerkily, a peculiar gait, which is almost indescrib- 
able. The tongue is affected, even in the mildest form, and the 
speech may be halting or stammering and thick. This is espe- 
cially true if the muscles of the larynx are involved. 

The choreic movements usually cease entirely during sleep, 
and may do so even in the severe forms. 

Relapses are very common. These may occur in a short time 
or a year or more may elapse between attacks. The duration is 
very variable, from a few weeks to several months, depending 
largely upon the time at which treatment is begun. 

Severe Chorea. — This form is essentially like the mild, except 
in the extent of muscular involvement and the severity of the 
twitchings and contractions. 

One case under my observation was admitted to tlie female ward of the 
City Hospital during my service. She was a girl 13 years of age, with a 



522 THE DISEASES OF CHILDREN. 

history of severe chorea for about a month. She had severe, general con- 
vulsive movements, v^ith traumatic bed sores upon the heels, hips, elbows 
and shoulder blades. Until the contractions could be controlled it was 
necessary to put padded sides to the bed to keep her from falling upon 
the floor. Mild twitchings were present during sleep. 

Diagnosis. — Posthemiplegic Chorea. — Choreiform movements 
may follow the cerebral palsies of infancy. They are usually 
of one extremity. Contractures occur as a rule in this form, 
followed by paralysis of the part. Epilepsy, hysteria, habit 
chorea, must be borne in mind and eliminated by exclusion. 

Pericarditis may occur, but is rarely seen. 

Treatment. — The first indication is to put the child to bed 
and at a complete rest, without a pillow, and with no book or 
other form of amusement. These patients invariably do better 
if removed from home, mother and friends, or if this is not 
possible put to bed at home, and in charge of a competent 
trained nurse, with family and friends excluded. This is very 
often difficult of accomplishment, and will be looked upon as in- 
human and cruel by the average mother, but by firmness, yet 
with tact, it can usually be done. 

This complete rest and isolation does more toward obtaining 
a cure than any other form of treatment, medical or otherwise. 
Some, and very often all, of the opposition to this rest may come 
from the patient, but it is usually overcome in a few days. 

The diet should be simple, regular and nutritious. Milk 
should, perhaps, be the basis of the diet, with later, eggs, farin- 
aceous food and vegetables. 

Gentle rubbing or massage following a daily Avarm bath is 
a valuable adjuvant in treatment. In some cases the galvanic 
current is of benefit. Bran and salt baths are of assistance. 

Medicinally, no one remedy offers the same advantages as ar- 
senic. A useful form is Fowler's solution, and it should be 
given in very gradually increasing doses. Begin with 1 to 3 
drops after meals and increase 1 drop a day at first then in- 
crease 1 drop each dose. If given in this way it can be increased 
to a much larger dose before physiologic effects are noted. 

Physiologic effects may show, as a puffing of the eyelids, 
usually the lower, or gastric and abdominal pain, cramping in 
character. Both symptoms may not be present in every case. 



DISEASES OF THE NERVOUS SYSTEM. 523 

In the case of the severe form referred to, the maximum dose reached, 
was 1 teaspoonful. It was then decreased in amount to 20 drops at the 
same ratio as increased ( 1 drop each dose ) , at which time she was prac- 
tically well, was up and walking about the yard. 

In one case, a boy of nine years, an inmate of an institution under treat- 
ment for his second attack of chorea, the arsenic was continued in in- 
creasing doses until 20 drops was reached before physiologic symptoms 
were noted. Instead of decreasing at this time, as customary, the maxi- 
mum dose was continued after the boy was dismissed from the institution 
infirmary. After taking the maximum dose for three weeks it was noticed 
he could not keep up in the school line because of a shuffling and hesitating 
gait. He was seen a few days later and a neuritis of both lower extremi- 
ties found. This was evidenced by delayed sensation of the foot, partial 
paralysis of the legs, and the reaction of degeneration of the muscles be- 
low the knees under static electricity. After discontinuance of the ar- 
senic he has greatly improved, but at the end of three months is still quite 
lame. 

Symptomatic treatment in all eases is indicated. Attention 
to the bowels is very necessary. Nightly doses of aromatic 
cascara are usually of great benefit. Enemata may be indicated. 

In the severe forms, in which there is a great muscular move- 
ment, the child must be controlled by the hypodermic admin- 
istration of morphia, the dose appropriate to the age. 

The temperature should not be taken in the mouth fj-om dan- 
ger of the thermometer being broken. 

The child should be kept from school for several months 
after apparent restoration of health. 

HEREDITARY CHOREA. 

Synonyms. — Huntington's clwrea: chronic chorea. 

Etiology. — This form of chorea is rare. There is always a 
distinct history of heredity perhaps in one or two generations- 
It is not a disease of childhood, occurring usually after the age 
of 20. It may affect one or more in the same family, but may 
develop in a young child of a sufferer from this form. 

Symptoms. — It is a disease of adult life, most cases occurring 
between 20 and 30 years of age. It is much like chorea minor, 
only the contractions are more severe, affecting chiefly the 
muscles of the face, peculiar grimaces being made, and of the 
arm and upper trunk. Sooner or later a mental condition de- 



524 THE DISEASES OF CHILDREN. 

velops, which is much like dementia, following a short period 
of irritability and apathy. 

Prognosis. — This is grave as to recovery. They may live 
years. 

Treatment. — No treatment is of avail, the only recourse be- 
ing confinement in an asylum or institution for the insane or 
feeble-minded. Symptomatic treatment is of course indicated. 

HABIT CHOREA. 

Synonym. — Convulsive tic. 

Symptoms. — This form of chorea occurs in the delicate and 
cachetic children, chiefly in those children who can best be de- 
scribed as "spoiled." The only manifestation may be a twitch- 
ing of a muscle of the face, contraction of one or both 
eyelids, raising the eyebrow, drawing down of a corner of the 
mouth, pulling down or up of one shoulder, contraction of the 
sternocleidomastoid muscle, pulling the head down and out, 
supinating or pronating the forearms, protruding the tongue, 
twitching of the fingers, etc. A starting point of this may be a 
binding of one of the articles of clothing, the shoulder for in- 
stance, being raised to relieve it of pressure. 

Diagnosis. — This is not always easily made from a mild 
chorea, except by the oft-repeated contractions of the same mus- 
cle or group of muscles, a purposeful movement. 

Peterson describes a condition which he calls gyrospasms of 
the head, the head being rotated to the right or left many times 
per minute and often accompanied by nystagmus. In these 
cases he found a history of rickets or intestinal irritation. 

Treatment. — The cause may be reflex and should be searched 
for, eye strain, phimosis, abnormalities of the ears and teeth, 
tight clothing, irritating underclothes, may be a cause, and if 
present, removed. 

The diet should be controlled, sweets entirely eliminated, and 
regular meals insisted upon. No tea or coffee should be allowed. 
Removal from school until relieved. Proper rest and regular 
hours for sleep. Daily warm baths followed by a cool sponge 
if possible, and a vigorous rub. Suggestion is of value in some 
cases. 



DISEASES OF THE NERVOUS SYSTEM. 525 

IMedicinally, arsenic is of value, alone or best in combination 
with the bromides. General tonics are indicated very often. 

ELECTRIC CHOREA. 

« 

This is a rare disease, so named because of the rapidity with 
which the movements follow one upon the other. They are 
violent as a rule. Dubini first described the condition in 1846. 

The muscles of the neck and face are principally affected, 
but the arms and legs may also be involved. After varying 
duration of the active choreiform condition, the cases are de- 
scribed as developing atrophy and paralyses in the affected 
muscles or group of muscles, with perhaps complete paralysis. 
There may be pain and an elevation of temperature, the symp- 
toms, collectively, and the termination suggesting a severe in- 
toxication. 

HYSTERIA. 

This is a comparatively rare condition in childhood, but occa- 
sionally seen about puberty or following this period. 

Etiology. — ^A ''neurotic" family history is usually present, 
and it occurs in the "spoiled" child, more often in girls. Over- 
crowding at school is a potent factor, fright, emotional and sen- 
sational plays and books may influence it. There is usually a 
history of the child being delicate, perhaps having had the ex- 
anthemata and other illnesses, a variable appetite, with frequent 
digestive disturbances. 

Symptoms. — These are usually divided into groups, accord- 
ing to the various systems involved, sensory, motor, mental or 
psychic. 

Sensory Manifestations. — These symptoms may be mani- 
fested by Jiypcrestlusia or anesthesia. The severity of the pain 
complained of is at once suggestive of the diagnosis. The slight- 
est touch or even if the patient thinks it will be touched causes 
severe complaint. The location of the pain or point of tender- 
ness does not correspond to the distribution of the nerve supply- 
ing the part. Anesthesia, if present, usually involves half the 
body, and of itself is a suggestive occurrence. Anesthesia of 
one area or region may also be present. 

Photophobia may be present, or complete loss of sight in one 



526 THE DISEASES OF CHILDREN. 

eye or loss of vision to part of the eye. The visceral form of 
hysteria . may be mentioned here. The patient may refuse food 
entirely, or if taken may shortly be followed by contraction of 
the stomach and vomiting without nausea. There may be diar- 
rhea in this form also. Tympanites is often present. Hyster- 
ical hiccough is encountered, and an inability to swallow. 
Globus hystericus, stricture of esophagus is not present. Nau- 
sea , and vomiting may occur. 

Motor Manifestations. — These are evidenced by a variety of 
convulsive movements which may affect the entire body or 
groups of muscles, one or both arms, or both legs, etc. Sensory 
symptoms may be present also. The following case is illus- 
trative of this type of hysteria : 

A 11-year-old girl was seen in consultation, who for three months had 
had severe "convulsions," occurring principally in the forenoon. The 
mother was thin, anemic, subject ol organic heart disease, and very 
"nervous." When shown into the child's room the mother said, after we 
had talked for a few moments: "Have one of your spells now, you've had 
them this morning." Very shortly the child began with convulsive, up-and- 
down movements of arms and forearms, tightly clenched its hands to- 
gether, moved up and down in bed, gave two or three long-drawn inspira- 
tions with its mouth tightly contracted and then relaxed, smiling shortly 
after. The knee reflexes were exaggerated. 

Hiccough is a frequent form of muscular contraction. Hys- 
terical aphonia is a common condition in hysteria, esophageal 
spasm being often associated. 

Mental or Psychic. — Usually wdth either of the other group 
of symptoms there is a decided perverted mental condition, the 
child being extremely emotional. The phenomenon usually 
called hysteria is frequent, uncontrollable laughter followed by 
crying, or vice versa. Sachs terms an exaggeration of this con- 
dition hysterical mania, the child trying to do itself or others 
violence, being in a frenzy. Sympathy may precipitate such 
an attack. 

Diagnosis. — If the motor symptoms are pronounced the 
trouble may have to be diagnosed from epileps}^ The child is 
in a condition of hysteroepilepsy. In this form of convulsive 
attack there is no aura, the onset is gradual, there may be 



DISEASES OE THE NERVOUS SYSTEM. 527 

noises made throughout the attack, there is no impairment of 
vesical and rectal reflexes; the attacks last much longer, fol- 
lowed usually by a condition of trance; biting of the tongue is 
rare. 

Treatment. — As in chorea, only the indication is even more 
pronounced, the first thing to be accomplished is to isolate the 
child from family and friends. This is far easier and better 
done by removing the child to an institution for the sick, and 
isolate it with a special nurse. The choice of a nurse is very 
essential. She should be firm, yet kind, and the child made to 
understand from the beginning that the nurse is in authority 
in the absence of the physician and absolutely in control. As 
soon as the acute symptoms. are corrected the child should be 
placed under the care of a competent nurse or governess at home, 
and the same strict regime carried out there. AYhat teaching is 
done, must be at home and not at a general or i^rivate school. 
Later private schools are of benefit, with limited number of pu- 
pils where individual attention can be given. 

Careful written directions must be given in regard to the 
whole life and routine of the patient, diet, dress, habits, cloth- 
ing, exercise and play. 

Suggestive therapeutics in these cases are of the very greatest 
help, and should be carefully and conscientiously employed. 
Electricity may be classed under this head. 

In some cases, in older children, especially where hysterical 
paralyses and joints are encountered, blisters and the actual 
cautery are of the most signal benefit. It may not be necessary 
to use them, their exhibition and explanation of method of 
procedure is usually all that is needed for a complete "cure." 
Cold douches to the back are also efficacious. 

In the anorexia and vomiting, stomach washing and nasal 
feeding through tube, or gavage, usually brings prompt and 
favorable results. 

EPILEPSY. 

A functional disorder of the nervous system characterized by 
tonic and clonic convulsions at intervals, of the entire or a por- 
tion of the muscular system of the body, and attended by loss 
of consciousness. 



528 THE DISEASES OF CHILDREN. 

Etiology. — There is no distinct etiology which is present in 
all cases. Heredity plays an important role in the etiology, 
a history of epilepsy, insanity or severe nervous disease in the 
family being present in a majority of cases. Consanguinity, 
alcoholism, syphilis, trauma are given as causes. Infantile cer- 
ebral hemorrhages are also a cause. Females are more often 
affected. The majority of cases occur between 5 and 15 years 
of age. Many reflex irritations are capable of precipitating 
the attacks, as phimosis, dental irritation, intestinal inflamma- 
tions, visual defects, toxemias and intestinal parasites. Mas- 
turbation is also a cause. Frequent convulsions from reflex 
causes may eventuate in epilepsy. 

Pathology. — But little which is definite is known of the 
pathology of this trouble, except in those cases due to cerebral 
hemorrhages. Degenerative changes have been found in the 
ganglion cells, with hyperplasia of neuroglia tissues. Dana gives 
the chief change as an induration or sclerosis. 

Symptoms. — Two types are generally considered, petit mal 
and grand mat. 

Petit Mal. — In this form of epilepsy there may be no con- 
vulsions but a temporary loss of consciousness which, because 
of the pallor present, may be diagnosed as a fainting attack. 

The frequent occurrence of this phenomenon should arouse 
suspicion at once. The child may be at play and suddenly stop, 
and will sit, perhaps fall down; its face will become pale, eyes 
staring, pupils dilated and unconsciousness will follow for a 
brief or a much longer period. The respiration may be snoring 
in character. When consciousness returns the child will have a 
dazed expression and will not be able to recognize its surround- 
ings. Usually there is no distinct aura, save, perhaps, a vague 
uneasiness felt by the patient, no preliminary cry and no in- 
voluntary passage of urine or feces. 

Grand Mal. — In this form, which is usually meant when the 
term epilepsy is used, several distinct stages are present, (1) 
aura, (2) cry, (3) tonic convulsions, (4) clonic convulsions, 
(5) unconsciousness. 

1. Aura or Preliminary Symptoms. — ^Premonitory symptoms 



DISEASES OF THE NERVOUS SYSTEM. 529 

may be felt by the patient for a number of hours before the 
active convulsive stage sets in. This may be only a feeling of 
giddiness, numbness, tingling, vague abdominal sensations, ex- 
citement or depression, aural or auditory symptoms. These 
warnings, if present always in the same form, enable the pa- 
tients to protect themselves from doing themselves bodily injury 
during the attack. The aura if present in the very young is not 
recognized as such by them. 

2. Initial Cry. — The cry which precedes the convulsive at- 
tack is usually quite pronounced. It may be hoarse and gut- 
tural, or a sharp, shrill cry, followed at once by the period of 
spasm and unconsciousness. 

3. Tonic Spasm. — This may begin as a twitching of the facial 
muscles, the eyes are open and turned up, pupils dilated, con- 
junctiva insensible and face pale. The body is rigid, the arms 
and legs slightly separated and extended, the fists clenched. 
This stage, lasting less than a minute, is followed closely by the 
stage of 

4. Clonic Convulsions. — Rhythmic contractions of the mus- 
cles of the face, arms, legs and body begin, in the order named. 
There is stertorous snoring respiration, with accumulation of 
foamy saliva in the mouth, blood tinged, if the tongue is bitten, 
cyanosis of the face and lips. The sphincters may be relaxed 
with involuntary passage of urine and feces. 

The active convulsions continue for two or three minutes, and 
gradually subside; cyanosis is followed by pallor, the pulse 
from being frequent and tense becomes feeble and slow, and 
the patient passes into the 

5. Stage of Unconsciousness or Coma. — In this stage the pa- 
tient usually goes into a profound sleep, lasting often several 
hours, from which he is with difficulty aroused, or the child may 
pass into a more or less natural sleep, lasting for a short time, 
and wakens in a dazed condition, not recognizing his surround- 
ings. A feeling of depression is usually felt for a day or so 
following. 

Diagnosis must be made from hysteria, uremia, Jacksonian 
epilepsy, or convulsions from reflex irritation: 



530 



THE DISEASES OF CHILDREN. 



EPILEPSY. 


HYSTERIA. 


UREMIA. 


Aura 


none 


none 


Sudden onset 


excitement usually pre- 
cedes 


gradual 


Loss of consciousness 


none 


yes 


Pupils dilated, fixed ; 


not altered 


constricted without 


anesthesia conjunctiva, 




anesthesia 


eyes rolled up 






Tonic convulsion short 


rigidity but no convul- 


more condition of stu- 


duration 


sions 


por 


Clonic convulsions var- 


may be tvvitcliings 


none 


ious parts body 






Foam on lips, perhaps 


none, do not bite tongue 


none 


bloody from biting 






tongue. 






Involuntary passage from 


usually none 


none 


bladder and bowel 






Usually history of re- 


as rule not as frequent 


none 


peated attacks 






Prolonged stupor follow- 


none 


none 


ing convulsions, may 


rare 


possible 


occur in sleep 







Urinary examination will reveal uremic nature of convulsions. 
In Jacksonian epilepsy the convulsions are unilateral, as a rule, 
perhaps affecting one leg or arm. 

Prognosis. — Cases rarely recover. The duration, frequency 
and severity of attacks influence the prognosis greatly. The 
outcome is usually the development of dementia. The prog- 
nosis is worse when epilepsy develops in the young. 

Treatment. — A careful investigation must be made to ascer- 
tain, if possible, any reflex cause, and that irritation removed. 
The various systems of the body should be reviewed and inves- 
tigated carefully: The eye, for refraction difficulties, muscle 
irregularities; the nose and naso-pharynx, for deflected septum, 
tumors, polyps, catarrhal inflammation, adenoids, etc. ; the mouth 
and gastrointestinal tract, for carious teeth, gastric insufficiency, 
dietetic errors, intestinal autointoxication or parasites, constipa- 
tion or diarrhea; genitourinary, phimosis, vesical irritation, 
kidney defects; the skin, for any lesions, etc., etc. 



DISEASES OF THE NERVOUS SYSTEM. 531 

The habits and life of the child should be inquired into care- 
fully, the diet regulated, hours of rest and sleep, form of exer- 
cise and play, ventilation of bedroom, clothing, etc., must re- 
ceive consideration. Coffee and tea should be prohibited. 

If the convulsive attacks are very frequent and severe, these 
patients do best in a home for epileptics where they are con- 
stantly under observation. 

In the control of the diet the method advised by Richet and 
Foulouse,^ of withdrawal of salt from the food or at least a 
great diminution in its use, is worthy of trial, as excellent results 
have been reported from this simple procedure. It is reported 
that the convulsions are lessened in frequency and are much 
less severe. 

A large number of drugs have been advocated in the treat- 
ment of epilepsy, the most generally used, and I might say 
also, abused, being the bromides. The bromides are of unques- 
tioned value, but they also are capable of considerable harm if 
used indiscriminately. They do not cure the case, but do influ- 
ence the attacks, both in frequency and severity. Ten grains 
of any of this group or a combination of the different salts every 
three hours during the day, to a maximum daily dose of 50 to 
60 grains, will prove of benefit. The bromide of strontium is 
one of the most efficacious of the salts. 

The fetid breath and bromide rash are evidences of satura- 
tion which indicates a discontinuance of the drug temporarily. 

During bromide administration careful attention to the 
bowels is most essential. The giving of arsenic to limit the 
skin eruption has been suggested. 

Confirmed epileptics do much better when segregated in a 
country home. 

The decompression operation upon the brain offers some re- 
lief in certain cases. 

DISORDERS OF SLEEP. 

The new-born infant sleeps 20 to 22 hours in the 24, unless 
disturbed from some cause. When from three to four months 
old, it lies awake longer periods at a time during the day, but 
should sleep all night, waking for but one feeding from 9 p. m. 

^ Paris Academy of Science, November, 1889. 



532 THE DISEASES OF CHILDREN. 

to 6 a. m. When six months old it should have no feeding 
at night, and sleep from 9 p. m. to 6 a. m. 

The chief causes of disturbance of sleep lie in the respiratory 
tract and the gastrointestinal canal. 

Catarrhal conditions of the nose, adenoids and enlarged 
tonsils which prevent the free passage of air into the lungs, 
cause great restlessness and loss of sleep. An elongated uvula 
may irritate the pharynx enough to cause an incessant coughing. 

Too frequent feeding, too rapid nursing, too hot or too cold 
milk, prolonged breast feeding, will all cause discomfort, from 
indigestion, the child crying out in sleep and showing great 
restlessness. 

It takes an almost incredibly short time for an infant to 
acquire bad habits of nursing, being held and rocked after 
feeding, etc., and a far greater length of time to correct these. 
bad habits. Mothers and nurses are too often responsible for 
restless babies. The use of rubber napkins and failure to 
change the child through the night also cause restlessness. Im- 
perfect ventilation, too little or too much cover may contribute 
to sleeplessness. 

Older children need the same routine of hours for feeding 
and bed as the infants. Until the child is six years old it should 
be fed a very simple supper and be put to bed before 7 o'clock. 
Keeping children up late or showing them off to visitors at all 
hours of the evening or night cannot be too strongly condemned. 

Telling exciting stories, threats of someone getting them and 
dark rooms strike terror in the hearts of most children, and 
may be the principal cause of night terrors {pavor noctiirniis). 
During one of these attacks the child has a wide-eyed stare, 
does not recognize those around, may c^y out, has hurried 
respirations, and is wakened to consciousness with difficulty. 
This condition may continue for some time, an hour or more, 
and the child fall into a deep sleep or waken crying, shortly to 
fall asleep again. As a rule it has no recollection of the occur- 
rence on awakening in the morning. 

If often repeated the cause of the disturbance must be located. 
If the last meal at night has been too large it must be regulated ; 
no exciting stories or books or boisterous play should be allowed. 



DISEASES OF THE NERVOUS SYSTEM. 533 

It should be carefully examined for any irritation, defect or 
abnormality which may possibly act as an exciting cause. 

The administration of a 5 or 10 grain dose of the bromides is 
indicated in certain cases in which control cannot be had of 
the case by eliminating the cause. 

ORGANIC NERVOUS DISEASES. 

Diseases of the Peripheral Nerves. 
There may be an inflammation of a group of the peripheral 
nerves, neuritis, or an involvement of the entire system of 
peripheral nerves, a multiple neuritis. 

MULTIPLE NEURITIS. 

Etiology. — An intoxication of the system with invasion of 
the nerve tissue with microorganisms, or the effect of the toxins 
on them, is the active cause, but exposure to wet and cold, 
trauma or pressure are predisposing causes most frequently 
met with. Diphtheria toxin is the most striking example of 
this. Prolonged administration of arsenic and lead poisoning 
are given as causes. 

Pathology. — Inflammation and degeneration may be present 
in this condition, and occur in the same nerve at different points. 
There may be an inflammation of the sheath, the endonurium 
may show an interstitial neuritis or the nerve tissue itself a 
parenchymatous neuritis. In the latter type the destruction is 
so great that the condition is Jike a degeneration, if not identical. 
If the degeneration is very extensive and severe there may be 
an entire destruction of the nerve tissue, leaving nothing but 
the sheath. Secondary degeneration is the form which usually 
takes place in the peripheral nerves. If the cells in the anterior 
horns of the cord degenerate there is degeneration also in the 
motor nerves. Regeneration may take place in degenerated 
nerves. 

Symptoms. — ^The typical type of this form of neuritis is that 
caused by the toxin of diphtheria. It is rare in infants, but a 
number of cases have been reported in children from five years 
up." It is much more rarely seen since the general use of 
diphtheria antitoxin. 



534 THE DISEASES OF CHILDREN. 

The onset is sudden, with frequently an initial chill, perhaps 
convulsions ; there are pains and sensitiveness in the extremities, 
chiefly the lower; fever may run high, 103° to 104° F. The 
child is extremely weak, and unable to stand. The pains con- 
tinue, the muscles begin to atrophy and paralysis sets in. The 
reflexes are diminished or lost entirely. Hyperesthesia followed 
by anesthesia may occur, the latter being due both to pain and 
heat. Some of the muscles of the eye and throat may be 
paralyzed. Kegurgitation of food is present when the latter 
occurs. There is wrist drop and foot drop in the general form. 
No reaction takes place to the rapidly interrupted current, and 
the reaction to the galvanic current slow. 

Prognosis. — Eegeneration of the nerve tissues generally takes 
place and recovery occurs, in from one to three months. 

The prognosis depends somewhat upon the extent of the loss 
of electrical reactions. If the reaction of degeneration is com- 
plete the prognosis is more grave, as far as entire restoration of 
function is concerned. 

Treatment. — Complete rest in bed is the first indication. 
Pain being one of the first and chief symptoms it is the first to 
demand attention, if not relieved by the application of heat 
it must be relieved by an anodyne. Heroin, codeine or one 
of the coal-tar products can be used, the latter, however, with 
caution. Pyramidon is perhaps the safest. Moist heat is a 
help in obtaining comfort. Calomel as an initial remedy is 
indicated. Strychnia injected into the affected muscle has been 
advised. Among the drugs suggested are the following: PL ext. 
ergot, 3ss to 3i ; sodii salicylatis, gr. x. q 3 h. 

Electricity is of great service, the galvanic current being the 
form to use at first, but only after the acute symptoms have 
subsided. After a month or six weeks, with improvement the 
faradic current is indicated in connection with massage. 

FACIAL PALSY. 

Synonym. — Bell's Palsy. 

In this form of neuritis the seventh nerve is involved. 
Etiology. — Infection, exposure to cold, rheumatism, middle- 
ear inflammation, mastoid disease or following an operation 



DISEASES OF THE NERVOUS SYSTEM. 535 

for it, pressure by forceps blades in instrumental delivery, pro- 
longed second stage in deformed pelvis are given as causes. If 
central, the process may be due to a meningitis, or brain tumors. 

Symptoms. — The first symptom may be pain and tenderness 
under the lobe of the ear at the point of exit of the nerve, fol- 
lowed very soon by paralysis of motion of the muscles of one 
side of the face. 

The characteristic signs of Bell's palsy are the inability to 
close the eye on the affected side, the eye rotating upward when 
attempting to do so, inability to pucker the mouth as if to 
whistle, and a deflection of the tongue from the median line, 
toward the normal side. Older children may have difficulty in 
masticating their food. If the acute symptoms do not last very 
long the prospects for entire recovery are good. Atrophy of 
the muscles may follow. 

Diagnosis is chiefly to be made from lesions of the brain, 
which is usually easy, as paralyses of the upper extremities, one 
or both, are also apt to be present. 

Prognosis. — The majority of cases recover, practically with 
entire restoration of function of the muscles. The duration 
is from six weeks to five months. Continued reaction of degen- 
eration renders the prognosis less good. 

Treatment. — In all cases the use of cathartics is indicated, 
with rest in bed or on the bed while the pain under the ear lasts. 
A small fly blister, one-half inch square, placed at the point of 
exit of the nerve is of benefit. 

After the acute symptoms have subsided the weak galvanic 
current is used very gently, and just strong enough to contract 
the muscles. 

If there is much contracture of the mouth, the strain on the 
cheek can be relieved by bending soft wire with a small hook 
at the end for the mouth, the other end hooking over the ear. 

The administration of iron, salicylate of soda and arsenic may 
give good results. 

OBSTETRICAL PARALYSIS (Erb's). 

These palsies take their name from the fact that tliey appear 
after manipulations during labor. It is a result of injury to 



536 THE DISEASES OF CHILDREN. 

the brachial plexus of nerves and occurs when the head is pulled 
sharply to one side, or traction is made with the fingers in the 
axilla, in an effort to deliver the shoulders. It occurs about 
once in 2000 labors, and a small percentage of the cases are 
bilateral. 

The paralysis usually manifests itself about the third or fourth 
day after birth. The infraspinatus muscle is most involved. 
The child may move its forearm and hand, but makes no effort 
to move the arm from the body. At first, however, the whole 
arm is limp and motionless. 

If there is no improvement the deformity noticed is a slight 
inclination forward of the affected shoulder, an atrophy of the 
muscles of the upper arm and shoulder, and tendency to an 
inward and forward rotation of the arm so the thumb points 
rather backward instead of forward. The paralysis is flaccid 
in type, and there is no tendency at all to a spastic condition. 

There is a characteristic electric reaction varying from a loss 
to the faradic current to a complete reaction of degeneration. 
If there is no faradic response but the response to galvanism re- 
tained, even if but feebly, recovery may take place; if response 
to both currents is gone the recovery, if it takes place at all, will 
be greatly retarded. 

Treatment. — Nothing is indicated during the first two or 
three weeks. At the end of this time gentle rubbing, not deep 
massage, should be begun, with gradually increasing passive 
motion. At" the end of six to eight weeks, a very weak electric 
current is applied, using the current with which a reaction can 
be obtained. This is applied once a day or every other day, 
at first five minutes, then ten minutes at a time. 

DISEASES OF THE SPINAL CORD. 

Acute Poliomyelitis. 

Synonyms. — Infantile paralysis, Infantile spinal paralysis. 

History.^ — This form of paralysis was first described by 

Heine in 1840, his writings being more upon its end results 

than of the disease producing the paralysis. 

1 Much in this section is obtained from Monograph No. 4 — June 24 of Rockefeller 
Institute for Medical Research: "A Clinical Study of Acute Poliomyelitis," by Pea- 
body, Draper and Dochez. 



DISEASES OF THE NERVOUS SYSTEM. 537 

Numerous epidemics were studied and many contributions 
to the literature upon it were made. In 1905 Wickman described 
the patholog;^^ of the disease and called attention to its epi- 
demiology. 

Etiology. — ^Experimental production of the disease in mon- 
keys was accomplished by several laboratory workers in different 
countries, in 1909, and their results published almost simul- 
taneously. As a result of this work a bacterial cause has been 
ruled out and undoubted evidence developed that the infective 
agent belongs to the so-called filterable virus group. This virus 
is resistant to many destructive agents, but is readily destroyed 
by a 2 per cent solution of hydrogen peroxide, by menthol and 
corrosive sublimate. 

Epidemiology. — Wickman first called attention to the abor- 
tive and meningitic forms of the disease, and it has focused 
attention on a disease which is unique, in that its epidemic 
nature is not caused by a parasite. It follows lines of human 
contact and travel, and the so-called healthy ''carrier" is to be 
reckoned with in its dissemination. There is every evidence to 
support the theory that the port of entry into the system is the 
naso-pharynx, the tonsils and the upper respiratory tract. It 
has been shown that there is a direct lymphatic connection be- 
tween the naso-pharyngeal lymphatics and the subarachnoid 
space. 

The virus can be carried on articles of clothing, bedding, 
domestic pets, the fly, and by dust. 

The common belief among the laity that trauma has a part 
in the etiology can positively be ruled out. 

It occurs more frequently during the first three years of life, 
but adults are not immune. It may occur in more than one 
member of a family, boys are probably more often affected. 

Late investigators ^ claim to have transmitted the disease to 
monkeys. They conclude that the virus must be of protozoon 
nature. 

Epidemics of infantile paralysis are most frequent in the late 
summer and early autumnal months. Starr - has collated 44 
epidemics of infantile paralysis. Individual cases may and often 

1 Landsteiner and Ponper: ZtseV«r f T-vi—=^"-^-f n. Exp. Therap., 1909, ii, 377. 
^ Journal American Medical Association, vol. ii, no. 2. 



538 THE DISEASES OF CHILDREN. 

develop during an attack of acute gastrointestinal infection. 
It may also occur as a sequel to one of the exanthemata, par- 
ticularly scarlatina, this being due to the lowered resistance of 
the child and the increased susceptibility to the virus of this 
disease, though it occurs fully as frequently in the previously 
perfectly healthy. 

Pathology. — In the recent investigations it has been shown 
that poliomyelitis is a general infection rather definite and 
constant changes being found in other organs than the nervous 
system. 

The meninges are edematous and injected. The brain and 
cord are edematous also. The cellular exudate, hemorrhage 
and edema are characteristic of the change occurring as a result 
of the action of this virus. 

Any section of the cord may be involved, the lumbar region 
perhaps most frequently, the cervical next in frequency. The 
process occurs chiefly in the anterior horns of gray matter, 
and it may vary from a simple congestion to an inflammation. 
This part of the cord has the most active blood supply, and it 
has been pointed out by different observers that the primary 
changes are in the blood vessels, and the degeneration which 
occurs in the ganglion cells are entirely secondary. As a result 
of this degeneration, the ganglion cells may disappear entirely, 
and the process may extend to the entire gray matter, which is 
often swollen and projects above the white matter. These 
changes occurring in the posterior root ganglia and the changes 
in the sensory ganglia possibly explain the pain present in the 
acute stage of the disease. 

The lymphoid tissue of the body, especially Peyer's patches 
and mesenteric glands show acute swelling. The superficial 
glands of the body, the tonsils, thymus gland and spleen are 
regularly enlarged. Cloudy swelling of other organs is described 
as present. The affected muscles show a characteristic change, 
many muscle fibers disappear entirely and the others are 
shrunken, the whole limb being atrophied, even the bone being 
smaller than that of the unaffected side. 

Symptoms. — The following clinical types have been described 
by Wickman: (1) spinal poliomyelitic form, (2) Landry's 



DISEASES OF THE XERVOUS SYSTEM. 539 

paralysis type, i 3^ bulbar or pontine form, (4) the encephalitic 
form, (5) the ataxic form, (6) the neiiritic iorm, (7) the 
meningeal form, (8) the abortive type. Peabody, Draper and 
Doehez advocate the classification into three main groups: (1) 
those cases in which the upper motor neurone is primarily 
affected, the cerebral group; ^2) the larger group of cases in 
which the lower motor neurone is involved, the bulbospinal 
group; and (3) the abortive cases, which do not become par- 
alyzed. It is more often seen in the robust, and if not as- 
sociated Avith otlier diseases is like an infectious disease in its 
onset. The period of incubation is very variable, but from ob- 
servation of cases occurring in the same family it is believed 
to be from one to four days. There are nearly always some 
prodromata : the child may awaken in the night, after a period 
of restlessness or perhaps, there has been listlessness during the 
previous two or three days. There may be anorexia, nausea or 
vomiting and fever to 102 "" F. or 104i^ F. and in those so inclined, 
even convulsions. A chill is comparatively rare. Sweating is 
sometimes present. Pain is present in the back of the head and 
in the alfected muscles. The acute symptoms last two or three 
days, during which time muscular weakness is present, when 
the paralysis is noted. Fever may continue for a week. Diar- 
rhea is seen often. The skin is very active. In contrast to the 
cases with severe prodramata there are cases which show but 
little indisposition, the paralysis being the first symptom noted, 
and the paralysis may be as severe in these cases as in the others. 
^Miiller claims there is a leucopenia present, but later authorities 
do not think it is a sign to be relied upon. There is a moderate 
increase in the pressure of the spinal fluid when lumbar puncture 
is done, and increase in the number of cells per cubic milli- 
meter; the type of the cells may be either mononuclear or poly- 
nuclear. The absence of the bacteria present in the spinal fluid 
in other meningitic infections make this method of dia-gnosis 
more important. 

In the usual form as described by Peabody, Draper and 
Doehez, the paralysis appears on the first or second day of the 
disease. The child is drowsy and lies on its back with legs 
slightly flexed and everted. It can be roused bv the gentlest 



540 THE DISEASES OF CHILDREN. 

touch or manipulation of an extremity. If it is the paralyzed 
limb which is moved the child will attempt to free it from the 
examiner's hand by a twisting motion of the body and shoulders, 
which is accompanied by a fretful look and whine. "When there 
is more meningeal irritation the position assumed is usually 
upon the side with more or less retraction and rigidity of the 
neck or opisthotonos. Crying or fretfulness may begin as soon 
as the bed is approached. Ocular paralyses may be present, 
sometimes photophobia. The throat is usually congested and 
tonsils swollen, tongue coated, enlargement of superficial lymph 
nodes. Most rales may be found in the chest without coincident 
temperature. 

The paralysis makes its appearance rather suddenly as a rule. 
In infants it may be recognized only after prolonged watching 
at the bedside. 

The reflexes, both superficial and deep, vary considerably^ 
Sweating, both general and localized, may be present. Reten- 
tion of urine may be seen. Constipation is the rule. 

Pain is a constant feature and a symptom which is not gen- 
erally attributed to this form of paralysis. Three types are 
described : pain on manipulation ; spontaneous pain ; and tender- 
ness on pressure over the muscles and nerve trunks. As stated 
a few cases may be seen in which the illness apparently began 
with the paralysis. Their appearance and symptoms are much 
as the type just de;scribed. 

In the so-called meningitic or cerebral form there is a marked 
disturbance of the sensorium. Profound stupor follows the 
drowsiness of the ordinary form, and the picture is much that 
of a patient with tubercular meningitis, and it may require a 
tuberculin test to differentiate. After a varying length of time, 
the stupor clears up, the child passing through a period of 
fretfulness and irritability. 

Paralyses. — The paralysis is of the flaccid type, of lower 
neurone destruction, without contractures, associated very soon 
with atrophy, the electric reactions are altered, the sensation is 
not greatly impaired though it may be tender and the reflexes 
diminished or lost in the affected limb. The affected part is cold 
and often cyanosed. 



DISEASES OF THE NERVOUS SYSTEM. 541 

The paralysis at first may involve the entire extremity, and as 
the inflammation or congestion subsides restoration of function 
in all but a single muscle or group of muscles takes place. This 
is a characteristic symptom of infantile paralysis. This im- 
provement usually occurs within the first three months. 

The atrophy is progressive until the difference in the two sides 
is quite marked. The chief cause of deformities is the strength 
of the opposing muscles. 

The paralyses are not symmetrical in their distribution, as 
one leg and one arm may be affected or the perineal muscles 
of one side and the face. 

The electrical reaction is that of complete degeneration, com- 
plete loss of faradic and galvanic response in the nerves, and 
delayed galvanic response in the muscles. 

Diagnosis. — In many cases the diagnosis is not made until 
the development of the paralysis. The acute condition may be 
mistaken for any of the acute intoxications according to the 
predominance of the symptoms. The chief condition which may 
be confused with infantile paralysis is cerebrospinal meningitis, 
but the convulsions of infantile paralj^sis occur only at the on- 
set, and none of the other meningeal symptoms are present. 

In the acute cerebral palsies the chief diagnostic symptom 
is the spastic nature of the palsy, without atrophy; its hemi- 
plegic nature; the normal electric reaction, with not infrequent 
involvement of the mind. The reflexes in the cerebral type are 
exaggerated also. 

In neuritis the pain is a prominent symptom, which is usually 
less in poliomyelitis, but in other respects the symptoms are 
much the same, viz., paralysis, atrophy and electrical phe- 
nomena. 

Prognosis. — The mortality in sporadic cases is small, and in 
epidemics from 6 to 10 per cent. In Wickman's series of 868 
cases the mortality was. 16. 7 per cent. Death occurs most often 
on the fourth day of the paralysis, though they are not out of 
danger until after the eighth day from the beginning of the 
muscular weakness. There is no way of giving an accurate 
prognosis in the beginning of an attack, as often a very hopeless 
looking case will show regeneration of a number of muscles 



542 THE DISEASES OF CHILDREN. 

which at first showed complete paralysis. The family should, 
however, be put in complete possession of facts, and the possible 
outcome, emphasizing the favorable symptoms always, but there 
is absolutely no way of anticipating the paralysis. A number 
of cases have been reported showing complete recovery. 

Treatment. — Steps must be taken at once the diagnosis is 
made to establish a strict quarantine. In view of the fact 
that the virus in experimental work on monkeys has been 
found rarely to persist after three weeks, it is safe to isolate 
affected children for four weeks from the beginning of the attack. 
In the acute stage dry cups along the spine may be beneficial. 
Hydrotherapy is of great benefit. In this stage an anodyne is 
needed for the pain unless it is controlled by the application 
of a splint or bandage. The application of an ice bag to the 
spine is of great benefit and comfort. Absolute rest in bed is 
the chief indication. 

Attention should be given to the bowels, an initial calomel 
purge being of benefit. The diet should be bland and easily 
digested, and a minimum of sweets given. 

Careful nursing by a trained and competent nurse should be 
insisted upon. 

With the first evidence of contracture of opposing muscles 
enough to cause deformity, a brace should be so applied as to 
overcome this, or the leg held in place by sand bags. If the con- 
traction is very great before the brace is applied, a tenotomy of 
the opposing muscle should be performed, followed by applica- 
tion of a plaster of dressing with the part being slightly 
over-corrected. 

Massage is of great service after the acute symptoms have 
begun to subside, to exercise the flaccid muscles. Muscle train- 
ing is of great assistance. Electricity is to be used for this 
purpose also. In the early stages galvanism should be used on 
the nerve trunks and f aradism on the muscles so long as theiv 
irritability for contraction is maintained. When irritability 
of contraction to the faradic is lost galvanism should be used. 
It should not be applied oftener than once a day, 10 or 15 
minutes at a time, and continued for several months, and should 
be used only b}^ those expert in its application. 



DISEASES OF THE NERVOUS SYSTEM. 543 

Much lias been accomplished in the last few years in the 
treatment of marked deformities in the transplantation of ten- 
dons, for the technic of which the reader is referred to any 
of the late works on surgery. 

Not much improvement can be looked for for several weeks, 
when an evidence of regeneration will show by return of function 
in some muscles. It is advised to give hexamethylenamine, gr. 
V, every four hours, to child of eight years (Gushing). Salicy- 
late of sodium or strontium can be used to advantage. 

ACUTE MYELITIS. 

An inflammation of the entire substance of the cord, in a 
transverse section, or over an extensive area. 

Etiology. — ^This is essentially an acute infection, occurring 
independently or as a sequel to one of the acute infectious dis- 
eases or exanthemata. It may also result from an extensioji 
downward of a primary meningeal lesion. Congenital syphilis 
and Pott's disease are among the active causes. Trauma, re- 
sulting in pressure or hemorrhage into the cord may be the 
cause. The causes given in the adult form, as alcohol, lead, 
mercury, etc., can practically be eliminated in children. 

Pathology. — There is no regularity in the extent of involve- 
ment or limitation of the segments involved, as two or more 
portions of the cord may be affected with normal tissue between. 
The dorsal portion has been found most often involved. The 
chief, and perhaps primary, changes are in the blood vessels, the 
blood supply is interfered with, there are minute hemorrhages 
in the gray matter and softening occurs. The meninges are 
congested and swollen. The white and gray matter are not 
distinct. The cord substance is destroyed and is soft and creamy 
in consistence. The process described extends to the nerve roots 
also. 

Symptoms. — These vary greatly, and because of the variety 
in symptoms the cases have been grouped into acute, subacute 
and chronic forms. 

In the acute form the onset is sudden, and if of septic origin 
it begins with a chill and fever, usually above 102° F. There 
is pain in the back, varying with the site of the lesion. Tender- 
ness over the affected area is also present. If there is an entire 



544 THE DISEASES OF CHILDREN. 

transverse inflammation the function of all muscles below this 
level are interfered with, including the sphincters. If the upper 
part of the cord is affected the arms are also paralyzed. Com- 
plete anesthesia is present extending to a level of the lesion. All 
sensations, thermal, muscular pain and touch, are absent, and 
the patient does not feel as if the extremities were a part of 
him. 

If the lesion is in the cervical portion of the cord the par- 
alysis of the arms will be flaccid and of the lower extremities 
spastic in character. If the lower portion of the cord is affected 
the paralysis is of the lower extremities and is of the flaccid 
type, with loss of reflexes but without involvement of the arms. 
Trophic lesions will often develop in these cases, with develop^ 
ment of bed sores. If these are large and absorption from them 
possible, the temperature will be influenced. 

In male children priapism may be present in lumbar involve- 
ment, and in all cases disturbances of bladder and rectum take 
place. Involuntary passages of urine and feces frequently occur, 
though retention of urine is perhaps more frequently followed 
by cystitis. 

Diagnosis. — The clinical picture presented is fairly typical 
of this form of lesion. In hemorrhage into the cord the onset 
of the trouble is more sudden, without fever and without loss of 
reflexes, atrophy or reaction of degeneration. In hemorrhage 
the pain is not so great, if present at all. 

In multiple neuritis, if all of the extremities are involved, 
the paralysis is the same, while in myelitis the paralysis may be 
flaccid in the upper and spastic in the lower extremities. 

Prognosis. — A guarded prognosis should always be given. 
The more extensive the involvement and acute the symptoms 
the graver the prognosis. The early development of complica- 
tions, as bed sores, cystitis, etc., make the prognosis graver. 

In the subacute variety, regeneration may take place to some 
extent in the cord, and restoration of function to a certain 
extent be possible. In syphilitic cases good results are obtained 
from specific treatment. 

The younger the child the graver the prognosis. 

Treatment.— The child will usually have been put to bed 



DISEASES OF THE NERVOUS SYSTEM. 545 

when first seen. If a young child, positive orders must be given 
that it be not taken from the bed and held or rocked under 
any circumstances. 

Local application of cold by a long ice bag is of service and 
should be applied intermittently. The tendency to trophic dis- 
orders should be remembered, and the long-continued applica- 
tion not allowed. The bladder and bowels must be closelj^ 
watched. Extra precautions must be taken if catheterization 
is needed. The position of the child must be changed often and 
the skin of the dependent parts closely guarded against bed 
sores. Most careful attention must be given the bed sore if 
the skin breaks down. Ichthyol ointment, 3 or 5 per cent, or 
balsam of Peru (M. xx) and castor oil (gi) are good dressings 
in these cases. A water bed or air mattress may prevent the 
development of bed sores. 

If improvement is shown the child must be carefully watched 
to keep it from using the affected parts. Judicious massage 
and rubbing should be used for exercise. 

In the syphilitic cases the early administration of appropriate 
remedies is indicated. 

Tonic treatment, especially out-of-door air, is indicated. If 
contractures develop, tenotomy and the proper orthopedic 
measures used to prevent and correct them. 

POTT'S DISEASE. 

No attempt is made to describe the condition of Pott's disease 
from the standpoint of the orthopedic surgeon, but only as 
relates to the changes it produces in the spinal cord. It is a 
fairly common condition in childhood, and is due to a tuber- 
cular osteitis. 

Owing to softening of the bony and intervertebral cartilage an 
angulation takes place in the spinal column, its lumen is nar- 
rowed and pressure is made on the cord. Yet it is surprising 
how great the deformity may be without any pressure symp- 
toms presenting. The inflammatory condition from the bone 
extends to the meninges and thence to the cord, or pressure 
symptoms may be present from the meningeal involvement alone. 

The cord may be softened and degeneration of the cord is 



546 



THE DISEASES OF CHILDREN. 



found above and below the point of pressure. Much the same 
condition is present as in myelitis. 




Fig. 85. — X-ray of Pott's disease involving first lumbar and last dorsal vertebrae. 

Symptoms. — The development of this condition is very slovv^ 
as a rule. Spastic paralysis is an early symptom and may be 
the first noted. Sensitiveness and pain are present when pres- 



DISEASES OP THE NERVOUS SYSTEM. 547 

sure is made, due to involvement of the nerve roots. Disturbed 
sensation may also be present. 

Diagnosis. — This is to be made principally from myelitis. 
A careful examination of the spine for deformity or rigidity 
should always be made in cases of suspected spinal cord lesion. 
In Pott's disease there is pain on pressure over the involved 
vertebra. In those cases in which the paralysis precedes 
the deformity the diagnosis may be difficult. 

Prognosis. — If the paralj^sis is entirely due to the pressure, 
with but little inflammation present in the cord, the process 
may be stopped by proper orthopedic measures, taken to relieve 
the deformity and pressure, by properly fitting appliances. 
However, the case is apt to be progressive, and the outlook for 
recovery very grave. 

Treatment. — The first positive indication is to relieve the 
pressure by prompt orthopedic measures. Perhaps rest in bed, 
entirely recumbent, may influence the condition, or in other 
cases plaster of Paris jackets are indicated. ' 

Fresh air, tonics, good food and hygiene are the chief indica- 
tions other than the surgical ones. 



TUMORS OF THE SPINAL CORD AND ITS COVERINGS. 

These growths are very rare in childhood. Syphilis and 
tuberculosis cause the majority. Malignancy may be the cause. 
Cysts and gliomata are also given as causes, the former due to 
hemorrhage. 

Symptoms. — The onset is very gradual, the symptoms vary- 
ing according to location of the tumor. If the meninges are 
principally involved there is pressure on the posterior roots 
and pain later after involvement of the meninges and roots takes 
place. Not infrequently only half of cord may be involved. 
The cervical and dorsal regions are perhaps most often affected. 
There is flaccid paralysis of one or both arms when located high 
up, and of the legs when lower in the cord. Atrophy soon 
develops in each. 

Diagnosis. — In Pott's disease the deformity is usually present 
and the course of the disease is longer. In myelitis the course 



548 THE DISEASES OF CHILDREN. 

is much more rapid, pain is not so prominent and paralysis 
sooner. 

In neuritis paralysis is present earlier and the rectum and 
bladder not involved. 

Prognosis. — This is unfavorable, as surgery offers but little 
hope. In syphilitic tumors some good may be accomplished by 
proper treatment. 

Treatment. — Except in syphilitic tumors, drugs ■ are of no 
avail. The iodides and mercury should be tried in every case, 
but their efficacy is doubtful. Operation for removal of the 
tumor should be performed if all other remedies fail, though 
it is an operation with but little hope of relief, and most diffi- 
cult to perform. 

SYPHILIS OF SPINAL CORD. 

The infant, the subject of hereditary syphilis, is apt to de- 
velop this condition more often than if it is acquired. 

Pathology. — An involvement of the arteries is the most fre- 
quent lesion, an endarteritis or arteritis causing softening of 
the cord substance, as in myelitis. A meningitis is present, also 
gummata in the cord and brain. 

Symptoms. — ^These are not like those present in conditions 
just described. The onset is gradual; the paralyses follow a 
period of weakness of the muscles and inability to walk, and are 
more apt to be of the spastic variety. Pain or anesthesia, or 
both, are present, varying according to the involvement of the 
roots. Reflexes are usually increased, sphincteric reflexes may 
be interfered with. 

Usually there is an irregular distribution of the disease over 
the greater part of the cord. The dorsal enlargement is most 
often and severely affected. The process spreads irregularly 
to other portions of the cord, evidenced by irregular areas of 
loss of sensation here and there on trunk and extremities. . 

Diagnosis. — This is chiefly from 'myelitis. The history of 
syphilis or its manifestations in other parts of the body is an 
aid in diagnosis. In myelitis a whole cross-section of the cord 
is involved, and symptoms are the same on both sides below 
the level of the lesion; in syphilis the invasion of the cross- 



DISEASES OF THE NERVOUS SYSTEM. 549 

section of tlie cord is slow. Erb's statement that in syphilis 
there may be complete paralysis with but slight anesthesia and 
slight rigidity should also be remembered. 

In infantile spastic paraplegia the early appearance of the 
trouble and the absence of particular sensory symptoms makes 
the diagnosis clear. 

In infantile paralysis there is but little pain, and the irregular 
distribution of the paralysis, as the right arm and left leg, with 
the absence of sensory symptoms rules out syphilis. 

Treatment. — Mercurials and iodides are positively indicated, 
and the earlier they are given the better the prognosis. In the 
child the inunction of mercury is the best method of administra- 
tion, with gradually increasing doses of the iodide of potash. 
Fifty per cent ung. hydrargyri, with vaseline or lanolin, can 
be used, rubbing a piece the size of a small hazel nut into the 
flexures and groin once daily. 

With the development of acute coryza the iodides should be 
discontinued temporarily, and when resumed, begin with the 
minimum dose, and increase as before. 

DISSEMINATED SCLEROSIS. 

Synonyms. — Multiple cerehrospinal and insular sclerosis. 

According to Fotzke this disease may be manifest at birth or 
develop during the first year, but the larger number of cases 
are seen during the second decade. 

Etiology. — The infectious diseases are considered the most 
frequent causes. Among the other causes may be mentioned 
trauma, heredity and metallic poisoning (Oppenheim). 

Pathology. — There are irregular patches of sclerosis at vari- 
ous points in the central nervous system, brain, pons, medulla 
and cord. The growth is of fibrous tissue, an increase in neu- 
roglia tissue. Some changes take place in the blood vessels. 

Symptoms. — Following a brief period of weakness of the 
lower extremities, and sometimes the upper, there develops an 
intention tremor which is very noticeable. It is only present 
when the patient wills to make a movement, and in an effort to 
accomplish it the tremor takes place. The tremor becomes so 
marked that the patient cannot feed himself or drink from a 



550 . THE DISEASES OF CHILDREN. 

glass held in one or both hands. Next develops a difficulty in 
speech, which has been designated scanning speech. He speaks 
very slowly and deliberately. 

The eye symptoms are fairly characteristic. Nystagmus de- 
velops early, especially when looking from one side to the other. 
The visual field is narrower. The mind becomes .affected rather 
early. Hysterical attacks are common, memory is bad. 

The lower extremities develop a spastic paralysis, which 
greatly interferes with walking. 

There are no distinct or typical electrical reactions, the 
sphincters are not involved and, as a rule, atrophy of muscles 
does not take place unless there is sclerosis of the anterior horns, 
which occurs less frequently. 

Diagnosis. — In myelitis, sphincter relaxation and sensory phe- 
nomena are prominent symptoms. 

The association of the usual symptoms, intention tremor, 
scanning speech, mental symptoms and spastic paralysis are 
sufficient to make the diagnosis. 

Prognosis. — The condition is incurable and it is essentially 
a chronic disease. 

Treatment. — The patient should have a protracted rest in 
bed as soon as the diagnosis is made, especially if there is a 
decided intention tremor. General tonic treatment is of benefit, 
including hydrotherapy, electricity and massage, all intelli- 
gently applied. 

HEREDITARY ATAXIA. 

Synonyms. — Friedreich's disease; family disease of the cord. 

Etiology. — This is essentially a disease of early life, develop- 
ing in the majority of cases before the' tenth year. It is believed 
by some to be primarily due to an arrest of development of the 
cord. It may occur in several generations, and often several 
are affected in the same family, and usually of the same sex. 

Pathology. — The process is principally located in the pos- 
terior and lateral columns, though the entire cord is smaller 
than normal. The process is principally a sclerosis, either lo- 
cated entirely in the column of Goll or the columns of Burdach 



DISEASES OF THE NERVOUS SYSTEM. . 551 

or both, and generally the entire length of the cord is affected. 

Symptoms. — Generally the first symptom, if it is not present 
at birth, is a peculiar gait, the child being unsteady and awk- 
ward on its feet. It balances itself with feet separated, and the 
gait is much as it is in locomotor ataxia. Following this man- 
ifestation in the lower extremities, a spastic condition develops 
in them, and a loss of power in the upper extremities and a 
jerky movement of them when an attempt is made to grasp or 
pick up an object. Nystagmus may be present at this time 
also ptosis and strabismus may be present. The child talks 
thickly and later cannot be understood. Sensation is rarely 
interfered with. Deep reflexes are not present as a rule, the 
patellar reflexes cannot always be elicited. 

Deformities develop after the spastic stage sets in, particu- 
larly in the feet, the great toes being hyperextended, the other 
toes to a lesser degree. 

Mentality is much interfered w^ith as the disease progresses. 

Diagnosis. — Tahes resembles this form of ataxia, but it is 
practically never seen in children. In multiple sclerosis, the 
intention tremor and marked spastic gait are diagnostic signs. 

Prognosis.— These cases grow progressively worse until they 
are completely helpless, but life is often prolonged for years. 

Treatment. — Nothing can be done to influence the course of 
the disease. The patient can be made comfortable by attention 
to hygiene, diet, etc., correction of deformities by section of 
contracted tendons, etc., and medicinal treatment given as symp- 
toms arise. 

HEREDITARY SPASTIC PARALYSIS. 

A condition occurring as a family characteristic, in which 
there is a spastic paralysis chiefly affecting the lower extrem- 
ities, more rarely the upper. 

Cases present different symptoms according to the chief loca- 
tion of the pathological lesion, cerebral or spinal, or a combina- 
tion of both. 

In the spinal type the chief symptoms are spastic paraplegia, 
with contractures and increased reflexes, and the pathologic proc- 



552 THE DISEASES OF CHILDREN. 

ess is located in the pyramidal tracts of the lateral columns. In 
this type there is no evidence of cerebral involvement. 

In the cerehral type the first symptom to call attention to 
abnormality is an arrested cerebral development. If the disease 
develops early the child will not show the normal intellection 
of its age, or if older will soon develop idiocy. Blindness is 
often present. They are classed under the term amaurotic 
family idiocy. If of the cerebrospinal type the spastic condition 
above referred to develops in addition to the idiocy. 

Diagnosis. — The hereditary nature of the disease is character- 
istic. In congenital paralysis there is a history of convulsions^, 
and usually of a difficult labor, and no hereditary history. 

Prognosis. — These cases may live for years, but the outlook 
for recovery of mind is hopeless. 

Treatment is entirely of no avail, and is symptomatic. 

PROGRESSIVE MUSCULAR DYSTROPHY. 

Synonyms. — Primary myopathy, Idopathic muscular atrophy. 

A condition in which there is a progressive muscular weak- 
ness of a certain group of muscles; associated with atrophy. 

Etiology. — This is a family disease, several members being 
often affected, the transmission being through the mother. 

Pathology. — The pathology is chiefly in the muscles, the 
fibers being atrophied, the sheath being often filled with fat. 
The spinal cord and nerves are normal. In the pseudohyper- 
trophic form there is also an increase in fat between the fibers 
and an increase in the connective tissue. 

Symptoms. — Three types are generally described, pseudo- 
hypertrophy of the muscles; juvenile type (Erb's) ; and Land- 
ouzy-Dejerine's type, the latter the facioscapulo-humeral variety. 

In the La7idouzy-Dejerine's type the principal groups of 
muscles involved are those of the face and shoulder girdle. The 
first muscle to atrophy is the orbicularis oris, followed by the 
other facial muscles and of the shoulder girdle. 

Sachs ^ has given the following tabular description of the 
three : 



^ Sachs : Nervous Diseases of Children. 



DISEASES OF THE NERVOUS SYSTEM. 
TYPES OF PRIMARY DYSTROPHIES. 



553 





MUSCULAR 
PSEUDO- 
HYPERTROPHY 


JUVENILE FORM OF 
PROGRESSIVE 
MUSCULAR ATRO- 
PHY (ERB'S TYPE) 


TYPE LANDOUZY- 
DEJERINE 


Part first affected 


Legs (calves). 


Shoulder girdle 


Face and shoul- 












der girdle. 


Distribution 


of 


liypertro- 


Calves, rarely 


Muscles around 


None. 


phy 






thighs. 


shoulder gir- 
dle and pel- 




Jr J 
















vic girdle. 




Distribution 


of 


atrophy . . 


Thighs, deep 


Thighs, deep 


Face muscles. 








muscles of 


muscles of 


including lips 








back, shoul- 


back, upper 


and orbicu- 








der, and scap- 


arm. Hyper- 


laris palpe- 








ular muscles. 


t r p h i e d 


b r a r u m ; 






. 


Calves during 


parts may 


shoulder and 








later period ; 


become atro- 


scapular 








at that time 
also genera] 
atrophy. 


phic in later 
stage. 


muscles. 


Parts remaining 


normal . . 


Face, forearm. 


Face, forearm, 


Ft)rearm, hand 








and hand, ex- 


hand and leg 


and legs, and 








cept in last 


muscles ex- 


deep muscles 








stages. 


cept in last 
stages. 


of back. 



Ei'h^s type begins in late childhood, before puberty, and 
involves the muscles of the shoulder girdle, including the del- 
toid, the pelvic girdle and the back. Because of atrophy of the 
muscles of the back, the child stands with a decided arch in 
the back and lordosis, the shoulder blades are thrown backward 
and the shoulders forward. 

The legs are affected late in the disease. 

In the pseudolitjpertropliic form the principal change is in 
the calf of the legs and thighs. As the name implies, there is 
a decided increase in the size of the legs and thighs, with a coin- 
cident loss in power. The gait is a peculiar waddling one. 
When sitting on the floor characteristic positions are assumed 



554 



THE DISEASES OF CHILDREN. 



in attempting to get upon his feet. With the assistance of his 
hands he climbs up on himself, gradually assuming the erect 
posture, with the lordosis present, standing with feet wide apart. 
When prostrate upon the floor he cannot rise. When the 




Fig. 86. 



Fig. 87. 




Typical attitudes assumed by patient with pseudohypertrophic muscular paralysis. 
(Courtesy Dr. Frank L. Christian, Elmira, N. Y.) 



muscles of the arm and forearm are involved the same hypertro- 
phy takes place here. Late in the disease the face takes on a 
peculiar lack of expression and intelligence. 

Prognosis. — ^As to cure, this is grave. Arrest of the disease 
has been reported. 

Treatment. — The general tonic treatment is indicated, with 
massage, electricity, hydrotherapy, attention to diet, etc. 



DISEASES OF THE NERVOUS SYSTEM. 



555 



DISEASES OF THE MENINGES AND BRAIN. 
Meningitis. 

Several varieties of meningitis are named, simpel acute men- 
ingitis; tiihercular meningitis; cerehrospinal meningitis, with 
numerous subdivisions according- to the part involved and the 
etiology. 

Simple Acute Meningitis. 

Etiology. — This form of trouble is essentially due to an in- 
fection, either during the infectious dis- 
eases, typhoid fever, pneumonia, the exan- 
themata, influenza, nephritis, etc., to 
trauma or to emboli of a septic nature and 
middle-ear trouble. The pneumococcus, 
streptococcus, and staphylococcus^ typhoid 
and influenza bacilli are the organisms most 
freciuently found. 

Pathology. — The chief inflammatory 
changes are in the pia mater, followed by a 
change in the dura. The greatest involve- 
ment is at the base, principally the poste- 
rior portion. The serous membrane is red, 
thickened, dull and rough, covered with 
fibrin; this stage is followed by one of effu- 
sion, at the base or in the ventricles. This 
may be serum, or according to the infecting 
organism, purulent in character. 

Symptoms.-A short period of indisposi- ^^ft/^enWetent.TKu-- 
tion may be present, the nature of which is fa^'i^'p^SiTTis.''' "'''"''" 
not even suspected with gradual develop- 
ment of the symptoms, or it may begin with a convulsion, high 
fever and rapid pulse. There may also be severe headache, vom- 
iting of the projectile type, sleeplessness, restlessness, photo- 
phobia and rigidity of the neck. The convulsions may be re- 
peated. The temperature is usually high, 104:° F., but may 
average 101° F. or lO^T F. The pulse and respiration are apt 
to be irregular. Coma or stupor may be prominent. Opistho- 
tonos may occur shortly before death or in one of the con- 
vulsions. 




556 THE DISEASES OF CHILDREN. 

The duration is usually from ten days to three weeks, or even 
much longer. 

Prognosis. — This is grave. Recovery sometimes occurs, but 
the diagnosis is often questioned closely before admitting the 
correctness of it. 

Diagnosis. — Differential diagnosis from tubercular and epi- 
demic cerebrospinal meningitis considered later. In the pres- 
ence of convulsions as the primary symptom, the diagnosis 
should not be made until the various intoxications, as intestinal, 
etc., are eliminated, as they can be usually in a few days, at the 
most. Lumbar puncture wdll aid the diagnosis by examination 
of the fluid removed. 

Treatment. — Absolute quiet, in bed, in a darkened room. 
Purgation, preferably by calomel followed by a saline, is pos- 
sible, and the intermittent application of an ice bag to the head, 
at the base, sides and top, is beneficial. Hydrotherapy for the 
temperature and the administration of bromide and chloral for 
the control of the convulsions and restlessness. Iodides during 
convalescence is helpful. 

Liquid, perhaps predigested, nourishment and attention to 
the kidneys is important. 

EPIDEMIC CEREBROSPINAL MENINGITIS. 

Synonjnn. — Spotted fever. 

As the name implies, this form of meningitis occurs epidemic- 
ally, and is due to the specific organism, the diplococcus intra- 
cellularis. Dr. J. Lewis Smith wrote of the first case having 
occurred in the United States in 1806, since which time epi- 
demics have occurred in all parts of the countr^^ 

Etiology and Bacteriology. — The specific organism causing 
the disease is the diplococcus intracellularis or the meningo- 
coccus of Weichselbaum. It is described ^ as of slight viability 
on all media, the best being agar, to Avhich has been added sheep 
serum and 2 per cent glucose. Culturesi^were kept alive five or 
six days in this media. It is supposed to gain entrance to the 
system through the nasal mucous membrane and through the 



^Flexner: Journal American Medical Association, vol. II, no. 4. 



DISEASES OF THE NERVOUS SYSTEM. 557 

upper respiratory tract to the blood stream, or a direct infection 
through the lymph channels. 

Experimenting with guinea-pigs, the following conclusions 
were reached: {a) Cultures freshly isolated are more virulent; 
(5) cultures attenuated by artificial growth cannot be rejuve- 

"^^^ 



-«iJS» ••• 




Fig. 90. — Pure culture of meningococcus, 36 hours old. Note the irregular stain- 
ing, the arrangement in pairs of the biscuit-shaped organisms and the ap- 
proximation of the fiat surfaces of the individual bacteria. Note that the di- 
vision between the individual cocci cannot be determined in many instances. 
(Sophian: Epidemic Cerebrospinal Meningitis.) 

nated by passage through animals ;(c) autolysis of an attenuated 
culture may yield an extract which may be used as an adjuvant 
to increase the activity of other cultures; (d) quantities of cul- 
tures injected vary little in effect; (e) guinea-pigs respond 
relatively very poorly. The nasal mucous membrane has been 
demonstrated to be a carrier, and hence a disseminator of the 
meningococcus. 

The fact that the organism is present in the naso-pharynx of 
a healthy person shows how the disease may be transmitted 
by ''carriers.'" 

It occurs both in adults and children, cases as young as three 
months having been reported : Rotch ^ reports one case in an 
infant 2 J: hours old. 

Pathology. — The gross pathological changes are much like 
those in other varieties. There is an intense hyperemia of the 
meninges of brain and cord, which is followed by an exudate 



Archives of Pediatrics, October, 1908. 



558 



THE DISEASES OF CHILDREN. 



Series of Microphotographs Illustrating the Change in the 

Cerebrospinal Fluid Under the Influence of Serum 

Treatment with Improvement. 





Fig. 91. 



Fig. 92. 









Fig. 93. 



94. 



Fig. 
Fig. 

Fig. 
Fig. 



91. — Stained sediment of cerebrospinal fluid removed from a case of epidemic 
meningitis at the beginning of the disease, before serum treatment was insti- 
tuted. Note the presence of intra- and extracellular diplococci and pus-cells. 

92. — Appearance of sediment 24 hours after 30 cc. of serum had been in- 
jected subdurally. Note the marked diminution in the total number of bacteria 
and the fact that most of them are intracellular, only a few being extracellular. 
This condition was associated with evidence of clinical improvement in the 
disease. 

93. — Stained sediment of cerebrospinal fluid obtained 24 hours after the second 
dose of antimeningitis serum. Most of the bacteria have disappeared, the few 
remaining diplococci being intracellular. The pus-cells are more numerous, 
probably as a direct result of the beneficial action of the serum. 

94. — Sediment of the cerebrospinal fluid 48 hours after the third dose of 
serum. Bacteria have totally disappeared and the cytological picture is chang- 
ing. A moderate number of lymphocytes are beginning to appear. The patient 
at this stage was rapidly recovering, (Sophian: Epidemic Cerebrospinal 
Meningitis.) 



DISEASES OF THE NERVOUS SYSTEM. 559 

of thick seropus. The entire surface of the brain and cord is 
covered with the exudate, which also extends in the fissures of 
the brain, and between the pia and the cortex, and the ventricles 
may contain a large amount of fluid. The meningococcus is 
found in the cells and exudate, and larger numbers of poly- 
morphonuclear neutrophiles than lymphocytes are found. There 
is a high leucocytosis. 

Symptoms. — The onset is as a rule abrupt, but the diagnosis 
cannot be made on the first day of illness. Vomiting, followed 
by a chill or rigors and high temperature and very often con- 
vulsions, are among the early symptoms. Headache is con- 
stant and often agonizing; there is pain in back and neck and 
early delirium is frequent. Backward retraction of the head 
and back occur early with, rigidity of the neck. The vomiting 
at this stage is projectile in character. The whole picture is one 
of an overwhelming infection from the beginning. The fever 
ranges between 102° and 104° F., but may go very much higher. 
Reflexes are exaggerated. 

A characteristic symptom is the development of an eruption 
on the body, hemorrhagic in character, at first petechial, then 
larger bruise-like areas. Herpes is found on lips and face. 
Kernig's sign is usually present, also Babinski's reflex. Mace- 
wen's sign, or the production of a hollow note on percussion 
over the parietal bones is not a constant or easily obtained sign. 

Coma may develop early. Otitis media is sometimes present 
as a result of an early infection of the middle ear. Purulent 
conjunctivitis is often present, also corneal, bulbar and con- 
junctival anesthesia. Maier's^ observation of muscle soreness, 
especially in the lumbar, erector spinas, thigh and upper arm 
muscles, is a valuable sign. 

Several types are seen in the same epidemic, the fulminant 
and rapidly fatal cases, which die within two or three days; 
the milder cases, in which the symptoms are not nearly so 
severe, and those cases which are very mild and of short 
duration. 

Prognosis. — This, under former methods of treatment, has 
varied in different epidemics. Mortality was from 25 to 75 

iRoyer: Archives of Pediatrics, October, 1908. 



560 



THE DISEASES OF CHILDREN. 




Fig. 95.— Boy of eleven, ill forty-eight hours with epidemic meningitis. He was 
actively delirious so that he had to be held for the photograph. Note the pos- 
ture. The head markedly retracted, back bowed. (Sophian: Epidemic Cere- 
hrospirial Meningitis.) 




Fig. 96. — A boy of thirteen lying in the usual position of those ill with epidemic 
meningitis. (Courtesy Dr. B. Franklin Royer, Philadelphia.) 




Fig. 97. — Photograph of a boy ten and one-half years old, taken five days after 
the onset of epidemic meningitis, showing opisthotonos, (Courtesy Dr. B. 
Franklin Royer, Philadelphia.) 



DISEASES OF THE NERVOUS SYSTEM. 561 

per cent, while now, under the serum treatment, the recoveries 
have been 75 per cent. Dunn ^ reports a mortality of 19 per 
cent in 40 cases treated with the serum. Hence early diagnosis 
and treatment are very necessary. Flexner ^ states that so long 
as the diplococeus is still present in the exudate from the spinal 
canal, and the mechanical damage to the anatomic structure is 
not irreparable, the employment of the serum holds out hope 
of considerable benefit. As a result of serum treatment soon 
after injection, the diplococci tended to be greatly reduced in 
numbers, to disappear from the fluid part of the exudate, 
to become wholly intracellular, to present certain changes in 
appearance, as swelling and fragmentation, and to stain dif- 
fusely and indistinctly, and coincidently to lose viability in 
culture. 

The exudate in the meninges rapidly loses turbidity under 
influence of serum injections. 

Functional restoration of the meninges is certain even where 
the exudate has been purulent. Unfavorable indications after 
several injections of serum are, progressive increase in turbidity 
of exudate, rise in leucocytosis and greater persistence of the 
diplococci with retention of viability. Relapse is attended or 
ushered in by increased exudation of leucocytes in meninges, 
higher systemic leucocytosis, and reappearance of or increase 
in the numbers of diplococci; although they may not regain 
power to grow outside the body in cultures. 

Relapses during treatment are not very frequent, and rarely 
has a case terminated fatally during relapse when the treat- 
ment with serum has been resumed without delay and vigor- 
ously pushed. The recovery in serum-treated cases is in the 
great majority of instances complete. The number of compli- 
cations is small, deafness being a persistent defect. 

Diagnosis. — This is best cleared up by use of the lumbar 
puncture and examination of the cerebrospinal fluid for the 
specific organism. Ihjection of the fluid in guinea-pigs may be 
necessary to clear up the diagnosis. The occurrence of a second 
or third case in a vicinity is often sufficient to make the diagnosis. 

Counting and differentiating the cells in the cerebrospinal 



1 Archives of Pediatrics, October, 1908. ^ l^c. cit. 



562 THE DISEASES OP CHILDREN. 

fluid is of great assistance. In this type the polymorphonuclear 
cells predominate largely ; in the tubercular form the predomi- 
nating cells are lymphocytes, and they are few, and the fluid is 
much clearer. 

Treatment. — The serum treatment of this disease, with the 
serum discovered by Flexner, is the only one which offers any 
hope of cure. Of 393 cases reported by Flexner there was a 
recover}^ of 75 per cent. 

The signs of improvement in the case are shown usually 24 
hours after the injection. 

To Flexner is due the credit of developing the serum treat- 
ment of this disease. He describes the action and administra- 
tion of the remedy as follows: The action of the serum is anti- 
toxic and bacteriolytic, and is brought into contact with the 
germs by injection into the cerebrospinal canal after as much 
cerebrospinal fluid as possible has been drawn off. 

The serum is harmless and has brought about a decided 
reduction in the mortality in the disease, from 80 per cent to 
less than 30 per cent. After the first injection the number of 
meningococci free in the fluid outside the cells are decreased, 
after the second or third injection those in the cells are de- 
stroyed and. the amount of fluid is less. The serum should 
alw^ays be given by the subdural injection, never subcutaneously. 

Lumbar puncture should be performed in every suspicious 
case at once, and if the fluid is turbid 20 to 30 cc. of warmed 
serum injected. The fluid withdrawn must be examined for 
the organism, and if found the injection repeated daily until 
symptoms are improved. Forty-five cubic centimeters are 
recommended as the maximum dose of the serum, governed 
somewhat by the amount of resistance to the serum as it is 
injected. Doses of 30 cc. are necessary for good results. The 
dose should be repeated daily as long as diplococci are found in 
the spinal fluid. At least four daily doses should be given, 
even if the diplococci disappear earlier. In fulminant cases 
the injection can be given oftener than once in 24 hours. Re- 
appearance of diplococci is indication for repeating injections. 

As a result of the injections the temperature drops in from 
3 to 12 hours, and the other symptoms improve, especially the 



DISEASES OF THE XERA'OUS SYSTEM. 563 

headache and delirmm : pain and hyperesthesia are relieved, 
eoma is lessened, intelligenc-e slowly returns and nourishment 
is taken. The strabismus and Kernig's sign are more persist- 
ent. The polymorphonucdear leucocytes in the fluid increase 
in number after the lirst injection. 

The Cjuestion of control of epidemics is a most important one. 
In cities and to\\Tis in which an epidemic exists, strict ciuarantine 
of all cases should be maintained, and the nasopahryngeal secre- 
tion of recovered cases carefully examined bacteriologically. 
^luniL-ipalities can well afford the furnishing of the serum gratis. 

The General Treatment. — The patient should have most care- 
ful nursing. If very violent attendants must be provided to 
prevent the patient from doing himself an injury. Gavage and 
nasal feeding may have to be resorted to in those profoundly 
unconscious. Ice applied to the head and neck allays much of 
the restlessness. Free purgation should be maintained. Hydro- 
therapy for hyperpyrexia is of service. 

ACUTE ENCEPHALITIS. 

This is an intiammation of the brain tissue itself. 

Etiology. — Any of the acute infectious or contagious dis- 
eases may be the exciting cause of this condition. Influenza, 
the exanthemata, diphtheria, pertussis, pneumonia, erysipelas, 
ulcerative endocarditis, the acute septic diseases and meningitis 
may be causes. 

Pathology. — The primary condition is hemorrhagic, the in- 
flammatory areas surrounding these spots, round-cell infiltra- 
tion and degeneration take place. 

Symptoms. — It occurs in young children and is preceded by 
a short period of depression, restlessness and headache followed 
by great drowsiness or by coma. Convulsions may precede 
the active symptoms. There is fever up to 104' F. or 105' F., 
rapid and irregular pulse: shallow, hurried breathing, which 
becomes irregular or Cheyne-Stokes, as the disease progresses. 

Motor and sensory symptoms develop according to the area 
most involved. Kigidity of the neck is present early, paralysis 
or hemiplegia may present, ocular palsies often develop : deaf- 
ness is usually present early, and if recovery takes place the 
hearing is not reestablished. 



564 THE DISEASES OF CHILDREN. 

Prognosis. — This is very grave, but varies according to the 
extent of involvement of the brain. If some remission in the 
symptoms is noted by the end of the first week the prognosis 
is more favorable. 

Treatment. — Absolute rest; calomel purgation, ice to head 
and spine, and a blister to the cervical region of the spine. 
Supportive and sedative treatment may be indicated at differ- 
ent times. 

HYDROCEPHALUS. 

This is an accumulation of cerebrospinal fluid either in the 
subdural spaces or in the ventricles. It may be congenital or 
acquired, primary or secondary, acute or chronic. 

ACUTE HYDROCEPHALUS. 

Etiology. — Trauma may be a factor, and it probably is of 
microbic origin, though nothing definite is known of its cause. 
It may be due to tuberculosis or syphilis. A condition known 
as meningitis serosa may exist, following trauma or infectious 
diseases. 

Pathology. — Inflammation of the brain or meninges, venous 
or lymphatic stasis may be present. The accumulation of fluid 
in the ventricles may continue and be so great as to cause thin- 
ning of the brain from internal pressure. 

Symptoms. — Slight fever may usher in the condition, con- 
tinuing a few days and gradually subsiding, with perhaps a rise 
at a later date. Headache is one of the earliest of the sub- 
jective symptoms, associated with retraction of the neck, and 
probably opisthotonos. Bulging of the fontanelles takes place. 
Headache, blindness, stupor and coma may be present. As the 
fever drops to normal all of these symi)toms may be relieved 
for a short period, and again come on as the temperature rises. 
There may be no improvement, the child succumbs to intracranial 
pressure. The 0})posite may obtain, the symptoms growing less 
in severity and tlie chihl finally recovering. Symptoms are 
soirielimes relieved by lumbar puncture, nothing abnormal being 
found in tlie fluid. 

Prognosis. — This depends largely upon the cause of the con- 
dition and its severity. Cases do recover in which the diagnosis 



DISEASES OF THE NERVOUS SYSTEM. 565 

is positive. Recovery or amelioration of all symptoms but the 
blindness may occur. In general the prognosis is unfavorable. 
Treatment. — Lumbar puncture is indicated and should be 
repeated if the effects of the first have been good. This treat- 
ment gives the only hope of cure, as no medication is of avail. 

CHRONIC HYDROCEPHALUS. 

The typical form of this variety is the congenital type, though 
a further subdivision is made by some authorities. 

Etiology. — The cause of the congenital form is not known. 
I delivered a dead child at term mth an enormous hydro- 
cephalus, in which the cord was wrapped tightly around the neck 
three times, enough pressure being exerted to make a deep 
groove in the neck in which the coils of cord rested. 

It occurs where both parents are perfectly healthy, and not 
infrequently it is the first-born so affected, and later children 
are perfectly normal. Mother and daughter have been known 
to have a hydrocephalic first-born. Syphilis, alcoholism, tuber- 
culosis in the parents have been given as causes. 

In this form the head is enlarged at birth and may be the 
cause of dystocia. It continues to enlarge after birth. Not 
infrequently associated with the hydrocephalus is an imperfect 
closure of the spinal canal, spina bifida, or one of the varieties 
of talipes. 

Enormous accumulation of fluid may take place in the ven- 
tricles, distending them and compressing the brain until it is 
greatly attenuated. 

The sutures are widely separated, especially the frontal, 
coronal and sagittal, and the fontanelles are very large and 
bulging. 

Symptoms. — The first thing noticed in these infants is the 
ver}" high, bulging forehead, with an upward tilting of the 
eyes and a tendency to exophthalmos. As the fluid increases a 
nystagmus is apt to begin. There may be a stationary period in 
which the head does not enlarge, and the child may be able to 
hold it up without special support, but as the fluid increases 
in amount the head cannot be raised from the pillow or turned. 

It is often surprising the amount of intellection exhibited 



566 



THE DISEASES OF CHILDREN. 



in these cases, which at autopsy show such thinning of brain 
tissue. 




Fig. 98. — Hydrocephalus. Child six years old. 




Fig. 99. — Side view same child. 
The following history of child whose pictures are shown is of interest. 
Female, colored, 6 years old. Third child, others normal. Had a con- 
vulsion when 12 days old. Head began enlarging at 6 weeks. At 3 weeks 
had bronchitis; 2 years of age measles; 3 years whooping-cough. Cut first 
tooth at one year of age. Circumference of head 32| inches, from occipital 
protuberance to bridge of nose 29 inches. This child died when 6| years old. 

A case which was under my observation when an interne at 
the New York Infant Asylum was admitted during the service 
of Dr. L. Emmet Holt, and through whose courtesy the case 
was reported in the American Practitioner and News, January 
2, 1892. 

She was the fourth child of healthy, German parentage; head large and 
soft, with bulging fontanelles at birth. At the age of one month the head 
measured 19 inches in circumference, and while under observation the gain 
in circvimference was at the rate of half an inch a week. 



DISEASES OF THE NERVOUS SYSTEM. 567 

There was a divergent strabismus, axis of eyes turned upward, pupils ac- 
tive and followed light; no contractures, rigidities or convulsions. 

The child died at the age of four months, and the head was 24^ inches 
in circumference, 16 inches from ear tip to tip, and from occipital pro- 
tuberance to bridge of nose, 20 inches. Eighty-eight ounces of fluid were 
withdrawn by a trocar. The brain in its thickest portion at the base 
varied from ^ to 1 inch in thickness. There was free communication be- 
tween, the lateral ventricles and the third ventricle at the base. The 
medulla, pons and cerebellum appeared normal. There was no evidence of 
meningitis or tumor. 

Diagnosis. — This must be made from rachitis, and should be 
easy. The enlargement of bone at the centers of ossification, 
the other bony changes, headsweats, etc., make the diagnosis of 
rachitis easy. 

Prognosis. — This is always serious and a guarded opinion 
should be given, even where there is an apparent improvement 
in intellection and no progressive enlargement of the head. 

Treatment. — This is entirely symptomatic and palliative as no 
medicine which may be given can cause an absorption of the 
fluid. 

Drainage of the fluid by tapping the ventricles through the 
fontanelles or by lumbar puncture may prove efficacious in some 
cases, and should be repeated if found so. 

CEREBRAL PALSIES OF CHILDHOOD. 

Synonyms. — Spastic hemiplegia; spastic paraplegia or dip- 
legia. 

Etiology. — The most frequent and potent factor in the cause 
of these conditions is a much-delayed labor, in the flrst-born, 
very often, and the injudicious or faulty use of the obstetrical 
forceps. Asphyxia at the time of birth may play a part in its 
causation. Injury to the mother during the last weeks of gesta- 
tion may be a cause. Hemorrhages in the brain or brain in- 
juries are the active causes. 

Heredity should be considered. There may be a distinct 
history of similar children affected in the parents' family. 

The acute exanthemata may act as a cause of the acute palsies. 
Trauma after birth may also act as a cause. Convulsions and 
whooping-cough may give rise to pathologic conditions in the 
brain which would result in spastic paralysis. 



568 THE DISEASES OF CHILDREN. 

Pathology. — In those cases being present at birth, more severe 
lesions are generally found, as a porencephaly, defective devel- 
opment of the brain or parts of it; meningeal hemorrhages; 
cysts; thrombosis or embolism, meningitis or encephalitis, scler- 
osis, hydrocephalus, and failure of development of the cortical 
cells. 

Symptoms. — Usually three types are described, according to 
the body area involved, viz. : Cerebral spastic hemiplegia; spastic 
paraplegia. 

The symptoms vary according to the time of development, the 
situation and extent of the brain involvement. If it occurs di- 
rectly after birth there may be convulsions, coma and cyanosis. 
In those developing later, convulsions mark the onset. Many 
cases appear during the first year of life, and fully two-thirds, 
perhaps more, begin in the first three years of life. Convul- 
sions may recur at fairly regular intervals for some time after 
their onset. 

When of the leg, there is a decided limp and spastic gait. Some 
contracture is nearly always present. Athetoid and choreiform 
movements may be seen of the affected muscles. 

The paralyses are at first flaccid, but they rapidly become 
spastic, the paralyzed side remains smaller and undeveloped. 
Idiocy is one of the important sequels, it may develop in a short 
while after the onset of the trouble. 

In quadriplegia all four extremities are involved, extensive in- 
jury to the brain probably having taken place. All of the symp- 
toms in a hemiplegia are present in this form, only more 
severe. 

In paraplegia only the lower extremities are involved, and the 
lesion is very apt to be at the apex of the brain. 

Diagnosis. — The spastic character of the paralysis, the di- 
minished intelligence, age of patient and history of the onset is 
usually sufficient to make a diagnosis. Reflexes are normal or 
exaggerated in contradistinction to other similar conditions liav- 
ijig no reflexes. 

Prognosis. — This is unfavorable, but cases do show an im- 
provement when the severe form of paralysis was present early. 
The early development of failing intellection is grave. Repeated 



DISEASES OF THE NERVOUS SYSTEM. 569 

convulsions make the outlook bad. If no improvement takes 
place in the contractures, the prognosis is not so good. 

Treatment. — Prophylaxis is most important. Intelligent 
care of all labors, intelligent interference when indicated, ef- 
fectually prevent injuries occurring during childbirth. Owing 
to the idiocy, these cases do best where they are under constant 
surveillance, hence the importance of confining them at a public 
institution, if possible. 

Proper hygiene, diet and general supervision of the life of 
the child is necessary. Orthopedic surgery is indicated always, 
where large amount contractures are present. 

TUMORS OF THE BRAIN AND MENINGES. 

Tumors of the brain are comparatively frequent in childhood. 
Peterson has reported 335 cases as follows : 

TABLE I. 

Form of Tumor. No. of Cases. 

Tubercle 166 

Glioma 42 

Sarcoma 37 

Cyst 35 

Carcinoma 11 

Gliosarcoma 5 

Angiosarcoma 1 

Myxosarcoma 1 

Papillary epithelioma 1 

Gumma 1 

Not stated 35 

Total 335 

TABLE rr. 
Site of Tumor. No. of Cases. 

Cerebellum 105 

Pons Varolii 42 

Centrum oyale 41 

Basal ganglia and lateral ventricles 30 

Corpora quadrigemina and crura cerebri 25 

Cortex cerebri 23 

Medulla oblongata 7 

Fourth ventricle 

Base of brain S 

Total 287 



570 THE DISEASES OF CHILDREN. 

Tubercular tumors are more often met than any other variety, 
and they are found most frequently in the cerebellum. 

Etiology. — ^With the exception perhaps of gliomata, tumors 
of the brain are secondary to growths of like character else- 
where in the body. A glioma may result from an injury or 
blow. 

Pathology. — The tubercle may occasion a variety of growths 
and affect any part of the nervous system. It occurs a^ a soli- 
tary tubercle or as multiple tumors, and tuberculosis in other 
parts of the body, as the bronchial glands, lung, mesentery, etc., 
is the starting point of the infection. They vary in size very 
much, from a pea to a growth which occupies a greater portion 
of the brain. These tumors are as a rule encapsulated, and may 
on section show softened areas in the center. Bacilli may be 
demonstrated, and in this way they are differentiated from other 
varieties of tumor. 

Glioma is a growth which is found beneath the gray matter 
in the white matter, as a rule, though it may involve the former 
also. It is a slower growth than the others. An increase in the 
blood supply is present in the areas involved in this growth. The 
mass is not encapsulated, and is much softer than the surround- 
ing tissue. 

Cysts are quite frequently encountered — found in brains when 
least expected. The origin of these cysts was evidently a hemor- 
rhagic or other process occurring in infancy. 

Gumma may occur in hereditary syphilis, but is rare. 

Symptoms. — These may be considered from the standpoint 
of the intracranial pressure and cerebral localization of the 
growth. 

We believe that these growths are very frequently not diag- 
nosed on account of the vagueness and indefiniteness of the 
symptoms. They vary greatly according to the rapidity of the 
growth, the amount of intracranial pressure from it, coincident 
increased blood supply, and hydrocephalus which follows. 

Among the general symptoms may be mentioned : 

Headache. — This may be the most striking symptom, both as 
to its severity and persistence. The pain is boring or knifelike 
and causes restlessness, photophobia and the typical cephalic cry. 



DISEASES OF THE NERVOUS SYSTEM. 571 

If the meuiuges are involved it will be more severe and localized, 
perhaps associated with tenderness. 

Xausta and vomifing. in connection with a more or less contin- 
uous headache, in a child is a suspicions occurrence. The vom- 
iting, if projectile, is quite characteristic of brain involvement, 
and later it occurs without nausea and irrespective of food. 

ConmiUionSy in connection with headaches, are suspicious, and 
especially so if the projectile vomiting is also present. 

Teriigo and dizziness are quite commonly present. 

Optic neuritis, from the intracranial pressure, is an early 
symptom, perhaps preceded for a short time by choked disc. 
Blindness is not ttncommon. Only one side may be involved, 
usually it is dotible. A careful ophthalmoscopic examination of 
the eyes should be made in all suspicious cases. 

The pulse at the end becomes rapid and weak, and not infre- 
quently the respirations show the t;vpical Cheyne-Stokes' type. 

Localization Symptoms. — This is a special study in itself, 
and the reader is referred to any late text-book on nervous and 
mental diseases for a detailed description of these diagnostic 
methods. 

Diagnosis. — ^From abscess by the presence of fever, and pos- 
sibly sweats in the latter. Abscess also forms more cpiickly, and 
previous history, perhaps of middle ear or frontal sinus disease, 
which are suggestive. 

In fu'bercuJar meningitis which is prolonged the diagnosis 
may be difficult. Headache is usually more severe in meningitis. 
Lumbar puncttire is of assistance in making a diagnosis. 

Prognosis. — This is extremely grave no matter what the 
character of the growth, and even if diagnosed surgery olfers 
very little hope of cure. Gummata, one of the least frecpient 
forms of growth, may yield to specific treatment. 

Treatment. — Surgery is practically the only form of treat- 
ment which otfers any hope of relief, and the outlook is exceed- 
ingly grave : even with skilled surgery children bear operative 
measures on the brain badly. The coal-tar products, with caf- 
feine and codeine, may have to be tried for the relief of the 
headaches. The bromides and chloral are of service in certain 
cases, and the regulation of the diet most essential. 



572 THE DISEASES OF CHILDREN. 

Because of the disseminated form of the growth of glioma 
and sarcoma, operations for their removal are not as successful 
as in other forms. 

ABSCESS OF THE BRAIN. 

A much more frequent condition in children than in adults. 

Etiology. — The most frequent cause is a preceding middle- 
ear or mastoid suppuration. Trauma is also a frequent cause, 
and disease of the nose and frontal sinuses also. Abscess of the 
brain follows venous infection and lateral sinus involvement in 
middle-ear disease most frequently. 

Pathology. — Rarely, small, Avalled-off collections of pus may 
be found postmortem which were not previously suspected. 
Larger collections of pus may be walled off, others show no 
distinct limiting membrane. It may be located in any part of 
the brain, beneath the dura or external to it entirely. A num- 
ber of the pus-producing organisms may be found in the pus 
from these abscesses. They occur most often, perhaps, in the 
frontal and temperosphenoidal lobes. 

' Symptoms. — Abscesses located deep in the brain tissue may 
cause no symptoms unless they are large enough to give symp- 
toms of intracranial pressure. They are difficult of diagnosis. 
Following operations on the middle ear or mastoid, the diag- 
nosis is much easier. Headache, vomiting, irregular fever and 
rigors, drowsiness, coma or convulsions are a train of sjanptoms 
w^hich are convincing. Cerebral localization, as in brain tumors, 
must be brought into consideration if the site of the abscess is 
to be diagnosed. 

Diagnosis. — If a history of previous inflammations contigu- 
ous to the brain is obtainable, the diagnosis is easier. 

From solid tumors, the presence of rigors and irregular tem- 
perature is a diagnostic sign. 

In meningitis and inflammation of the lateral sinus, the onset 
is much more sudden and the range of temperature higher. In 
meningitis, in addition, there is apt to be retraction of the head 
and rigidity of the neck. 

An important diagnostic aid is a differential blood current. 

Prognosis. — This is extremely grave. It is influenced by the 



DISEASES OF THE NERVOUS SYSTEM. 573 

location, size and duration of the abscess, and its accessibility 
for surgical intervention. 

Treatment. — Prophylaxis is of importance in ear and nasal 
disease, especially of suppurating variety. Prevention of ex- 
tensive involvement in middle-ear abscess by early paracentesis 
is indicated in all cases. Free and radical operation in mastoid 
abscess is the best treatment. 

Brain abscess can be treated successfully only by surgery, and 
careful exploratory operation. 

INTRACRANIAL HEMORRHAGE. 

Hemorrhage within the skull of the new-born may be siil)- 
dural, or within the brain substance, cerebral. 

Etiology. — This may be due to the general hemorrhagic 
diathesis or disease, or if it is present at birth due to causes ex- 
isting during labor, either long-continued pressure during the 
second stage, trauma of forceps delivery, or forcible extraction 
of the after-coming head in breech presentations. 

Symptoms. — A large hemorrhage, siihdiiral in character, 
may be present at birth or occur shortly after, in which event the 
child is either still-born or asphyxiated. A hemorrhage is the 
most frequent cause of convulsions in the new-born. These are 
more often localized and not general. A hemorrhage of sufficient 
size to cause general convulsions is usually enough to cause the 
death of the child. If the hemorrhage is slow the pressure symp- 
toms will not be so severe and the child may live some time, and 
a condition of cerebral atrophy will develop. 

Cerebral hemorrhage is more often seen in older children, and 
may occur as a complication of the infectious diseases. The hem- 
orrhage causes a period of sudden unconsciousness, followed by a 
paralysis more or less extensive, according to the area involved 
by the compression. Recovery may take place, but rarely. 

Prognosis. — In subdural hemorrhage, if the primary as- 
phyxia is relieved, the child may recover, to be afflicted with one 
of the cerebral palsies later. 

Treatment. — Artificial respiration is used to overcome the 
primary asphyxia. Great discretion should always be used in 
labor as to when interference is justifiable, to intelligently choose 



574 THE DISEASES OF CHILDREN. 

between the evils resulting from prolonged labor and those which 
follow instrumental delivery. In competent hands forceps' will 
prevent trouble far more frequently than they will do haTm. 

After the occurrence of the hemorrhage but little can be done, 
medically or surgically. ' 



CHAPTER XXIII. 

DISEASES OF THE SKIN. 

Owing to the very delicate structure of the skin in childhood 
many skin diseases at that period are different from those seen 
in adults. At this age the skin is much more susceptible to 
effects of irritants, and a number of lesions may result from 
mechanical causes, heat or cold, light, medication, etc. 

INTERTRIGO. 

This is a very common condition, and is a chafing or rubbing 
off of the superficial skin, which has been previously macerated. 
Its most frequent site is the buttocks, in folds between the but- 
tocks, in the groins, and the scrotum. The chief cause is the 
practice of drying the napkins several times before washing 
them, or neglect in removal of fecal discharges. 

The primary lesion is an erythema, with deep congestion of 
the skin. Maceration takes place, and a superficial layer of epi- 
dermis is rubbed off. This leaves a moist, red surface, which, 
if an infection takes place, becomes inflamed, covered with pus 
and encrustations. 

Treatment. — Prophylaxis is most important. Intertrigo is 
generally an indication of carelessness on the part of the nurse. 
Napkins should be properly cared for, boiled daily, without 
strong alkaline washing powders. Soap should not be used on 
the skin of the buttocks frequently. A soft cloth and warm 
water should be used after evacuations, followed by a drying 
powder. 

When the first symptoms develop all digestive disturbances 
should be corrected, that the discharges may be as unirritating 
as possible and the urine examined for hyperacidity. The nap- 
kin should be changed immediately it is wet or soiled, both day 

575 



576 THE DISEASES OP CHILDREN. 

and night, and should not be used again without having been 
washed. 

Stearate of zinc powder applied to the affected area as soon 
as cleansed and dried will frequently correct the condition 
promptly. If much thickening and congestion of the skin is 
present, Lassar's paste will be found efficient. 

SUDAMINA, MILIARIA. 

This eruption, usually called "heat" is characterized by mi- 
nute papules, which are surmounted by transparent vesicles, due 
to the collection of sweat under the epidermis. Some erythema 
is seen between the patches. 

Associated with this rash is usually considerable itching, the 
child scratching even in its sleep. 

The eruption is general, but chiefly located on the chest, neck 
and back. 

The vesicles rupture leaving a roughened surface, followed by 
a fine, scaly or branny desquamation. 

Treatment. — Cool sponging, followed by drying with a soft 
cloth and free use of talcum powder, gives comfort and relief 
from the itching and assists in drying up of the vesicles. 

PARASITIC SKIN LESIONS. 
PEDICULOSIS. 

This is an infection of the hair of the body with animal para- 
sites, affecting the hair of the head, and in older children tho 
hair of the pubes and body. 

PEDICULOSIS CAPITIS. 

This form is due to the invasion of the hair of the head by the 
parasite pediculus capitis. 

The headlouse is grayish in color, 1 to 3 mm. in length, oval 
in shape, with six legs, containing claws arising from the anterior 
portion. One female is capable of laying about 50 eggs, which 
hatch in about a week, and the new parasites are capable of re- 
production in about three weeks. The eggs or nits are at- 
tached to the side of the hair one-fourth to one-half an inch from 



DISEASES OF THE SKIN. 577 

the scalp, usually two or three to a hair, and can be easily seen 
by the naked eye. The occipital and temporal regions are more 
thickly contaminated than the rest of the head. 

Pediculi obtain nourishment by sucking blood from the scalp, 
this causes severe itching, resulting in scratching, Avith abra- 
sions and infections of the skin, a variety of exudations forming 
on it. If many of these are present the postcervical and sub- 
maxillary glands may become enlarged from absorption of pus. 
With large encrustations and matting of the hair there is a 
very disagreeable odor to the head. 

, Diagnosis. — Examination of the head should always be made 
where great itching is present. The nits can easily be found, 
and usually a parasite, especially if a fine tooth comb is run 
through the hair. A pustular encrustation on the scalp and 
neck is a suspicious occurrence. 

Treatment. — Both the pediculi and the ova must be destroyed. 
If in a girl with long hair and the infection is very great, a cure 
will be much more rapid by cutting the hair or boxing it. In 
a boy this can be easily done. The use of the fine tooth comb 
is necessary. 

A number of remedies have been advocated, none, however, 
infallible. 

The head should be washed with green soap and the follow- 
ing applied: 

I^ Kerosene oil 

01. olivge aa Jiv 

M. Sig. : Applied to the hair and thoroughly rubbed in, the head tied 
up in a towel and allowed to remain over night. 

The hair is shampooed the next morning with green soap, 
and this treatment repeated each night for three nights. 

Tincture of coculus indicus, diluted one-third, can be applied 
in the same way; also bichloride of mercury, gr. i to the ounce 
of water. To soften and remove the ova a solution of bicarbon- 
ate of soda or of dilute acetic acid can be used to advantage. 

PEDICULOSIS CORPORIS. 

This is due to the pediculosis corporis, a louse larger than the 
headlouse. It reproduces itself in the underclothing, the ova 



578 THE DISEASES OF CHILDREN. 

being deposited in the seams and folds, and hatching in about a 
week. 

The parasite fixes itself upon the skin and sucks blood there- 
from, this causing great itching. The scratching is severe, both 
day and night, which is evidenced by the excoriations on the 
body wherever the finger nails can reach. ThC' site of severest 
itching is where the clothes fit the body closest, as the waist, 
shoulders, across the back, etc. An inspection of the body may 
not reveal the parasites, but they are found on the underclothes. 

This form of louse is rarely seen in infancy, and is uncom- 
mon in children of any age. It is found chiefly among the poor 
and uncleanly, but rarely among negroes. 

The diagnosis is chiefly to be made from scabies. 

The treatment cannot be successful without careful disinfec- 
tion of the clothing and daily change of the underclothes. 
Thorough soaking of the underclothes in a 1/20 carbolic acid 
solution, followed by boiling, is sufficient to sterilize them. 

The itching can be relieved by the use over the body of a 5 
per cent carbolic acid ointment. 

PEDICULOSIS PUBIS. 

This is only seen after puberty, and is due to an infection of 
the pubic hair by the pediculus pubis, or crab-louse, and is, of 
course, not seen in children before puberty. 

Occasionally these parasites infect the eyebrows and eyelashes. 
The parasites are smaller than the other forms of lice, and bury 
their heads in the hair follicles. The nits are deposited upon 
the hair and hatch in about the same time as the other varie- 
ties. 

The lice can be removed with forceps and the nits removed 
by vigorous rubbing and the application to the eyebrows of a 
carbolic acid ointment, 5 per cent, or a 50 per cent mercurial 
ointment with vaseline. 

SCABIES OR ITCH. 

This is due to the invasion of the skin by the sarcoptes 
scahiei or itch mite, and is characterized by burrows, in which 
the female lays her eggs, and intense itching. 



DISEASES OF THE SKIN. 579 

Symptoms. — It is a comparatively frequent occurrence in chil- 
dren, and especially in institutions, newly admitted children 
often bringing the infection. It is highly contagious. 

The female parasite burrows into the skin, these forming 
an irregular line about an eighth of an inch in length, elevated, 
grayish in color. 

The most frequent sites of the burrows are the back of the 
hands, between the fingers; the wrists; toes; inner sides of the 
thighs; the scrotum in males; around the waist and axillary 
region. 

A variety of eruptions are found over the affected areas, 
papules, vesicles, pustules, and excoriations due to the scratch- 
ing. 

Examined under a magnifying glass the acarus can be seen 
at one end of the burrow. 

The chief sj^mptom is the itching, most severe at night, dis- 
turbing greatly the rest and sleep of the child. The extent of 
the eruption depends upon the amount of pruritis and the coin- 
cident scratching. 

Wearing clothes formerly worn by an infected person, using 
the same towels, sleeping with one infected, or in an unchanged 
bed formerly occupied by an infected person, are the most fre- 
quent means of propagation. 

The female acarus is considerably larger than the male, easily 
seen with a magnifying glass. It is yellowish in color and ovoid 
in shape. The female perishes in the epidermis after depositing 
her ova in the burrow. 

Diagnosis is not always eas}^, but is suspicious whenever a 
case presents with severe itching and the multiform eruption 
upon the body as described above. The finding of the burrows, 
not always easy, is the diagnostic sign. Pediculi affect the body 
almost exclusively. 

Eczema must be differentiated. Except as a complication of 
scabies, so extensive an eczema with an arrangement as in 
scabies is unlikely to occur. 

Treatment. — The object of treatment is to destroy the acarus 
and relieve the resultant skin lesions. Sulphur, balsam of Peru 
and tar are the most efficient remedies. 



580 THE DISEASES OP CHILDREN. 

The child is given a hot bath with thorough soaping and vig- 
orous rub with rough towel afterward. The towel is boiled be- 
fore again being used. After this the whole body affected is 
anointed with an ointment containing sulphur, or sulphur and 
balsam of Peru, as follows: 



or 



B Sulphur precip. 


gr. 


xl 


Balsam Peruv. 


3i 




Adipis 






Vaseline 


an 5ss 




M. ft. ung. 






^ Beta naplithol 


gr. 


XX 


Balsam. Peru 


31 




or Sulphur precip. 


gr. 


xl 


Vaseline 


Ji 




M. ft. miCT. 







This method of treatment is repeated each of three succeed- 
ing nights, and at the end of this time precipitated sulphur is 
sprinkled between the sheets at bed time. Sheets and night 
clothes are changed each day. 

RINGWORM. 

Eingworm is named according to the site affected, of the scalp, 
tinea tonsurans; of the body, tinea circinata; of the groin, tinea 
cruris. 

Two spore fungi have been found as cause, of these conditions, 
the small spore, microsporon audouini, and the large spore, 
tricliophyion. 

There are several varieties of each fungus. 

TINEA CIRCINATA. 

Lesions due to the microsporon appear on any part of the 
body, often upon the backs of the hands. 

Symptoms. — It begins as a small, scaly, papular patch, soon 
assuming a circular form, the outer ring generally being slightly 
elevated and scaly. As the ring enlarges the skin within be- 
comes shiny and tense and of a deeper color than the healthy 
skin. One or two, or many ringworm patches, may be found. 
It may occur with or without an involvement of the scalp. 



DISEASES OF THE SKIN. 581 

One source of infection is through the medium of domestic 
pets, cats and dogs. 

Pathology. — A scraping from the scaly patch, treated with 
liquor potass^, 10 to 30 per cent solution, after 10 or 15 min- 
utes shows under the microscope a network of mycelial threads, 
bifurcated, with fewer spores. The latter are round, about 1/800 
of an inch in diameter. 

Treatment. — Painting the patches with the tincture of iodine 
is usually sufficient to cure. This may be repeated once daily 
for two or three days. Any of the parasiticide drugs in the 
Eorm of an ointment mav be used as follows : 



IJ Ung. sulpliuris 
Ac. carbohci 


gr.x 


:\r. ft. img. 




IJ Hydrargyri ammoniat. gr. xx 
Ung. ziiici oxidi 


Vaseline 


aa5ss 


M. ft. ung. 




U Beta napMhol 
Resorcin 


gr.xx 
gr. xii 


Ung. aquse rosge 
M. ft. img. 


5i 



TINEA TONSURANS. 

Synonyms. — Fingwonn of scalp. 

A disease of the scalp due to the tricophyton tonsurans, char- 
acterized by a disease of the hair which causes it to fall out, 
leaving circumscribed areas of baldness, with scaly surface. 

Etiology. — This disease is due to the tricophyton tonsurans, 
or the microsporon audouini. It affects children, in the main, 
and is directly transmitted from child to child, or through the 
medium of combs or brushes, towels, caps, bedding, etc. A 
cat, dog or rabbit may convey the organism. 

Pathology. — An examination of a hair from the diseased 
area, or a scale from the epidermis, treated with a 20 per cent 
potassa^ solution, the spores can be easily seen under the scale 
when viewed witli a 1/6 inch lens. Thev are attached in num- 



582 THE DISEASES OF CHILDREN. 

bers to the hair, and the mycelial threads run longitudinally. 
The hair is broken off leaving a rough end. 

Symptoms. — The disease begins upon any portion of the 
scalp, being at first limited to the scalp, but later on affecting 
the hair and hair follicle. The period in which only the scalp 
is involved may be entirely overlooked as practically no symp- 
toms present. The first evidence may be a bald spot appearing 
upon some part of the scalp, the hair being broken off and the 
skin in the area, as a rule, scaly in appearance. These areas 
vary in size from a five-cent piece to the size of a silver dollar. 
On an attempt to pull out a hair in the diseased area the hair 
breaks close to the scalp. 

A differentiation is made by derm^-^ologists of the lesion caused 
by the large and small spores. In \e large-spored type, or the 
tricophyton or endothrix variety, U e lesions are much smaller 
in size than the small-spored type. " 

The course of the disease is slow and prolonged, as it may 
remain for years if treatment is not instituted and conscien- 
tiously carried out. 

Diagnosis. — The occurrence of circumscribed areas of bald- 
ness in one or more places in the scalp is characteristic of ring- 
worm. An examination of the hair treated by liquor potassae 
under the microscope will clear up the diagnosis. 

It must be diagnosed from alopecia. This is usually more 
rapid in its course, and the scalp affected smooth and soft, the 
hair apparently normal, at least not brittle, and contains no 
spores. 

Prognosis. — This is one of the most intractable of the skin 
lesions of childhood, and requires several months of active and 
persistent treatment before a cure can be obtained. 

Treatment. — Careful segregati5n of ringworm subjects 
should be insisted upon, and they should be made to wear a 
skull cap made of muslin at all times so as to prevent the dis- 
semination of scales and broken hairs containing the spores. 

The hair should be closely clipped from the whole head, or 
if a girl, and this is objected to, a small area around the af- 
fected spot should be closely cut. The diseased area is vigor- 
ously rubbed with green soap, or its tincture, and with a nail 



DISEASES OF THE SKIN. 583 

brush thoroughly scrubbed each morning, followed by the appli- 
cation of the medicament decided upon, for the purpose of de- 
stroying the spores. This can be done only by producing an 
inflammatory reaction in the skin of the affected area. The fol- 
lowing has been recommended as effective for this purpose : 

I^ Sodium cliloridi 

Vaseline aa 5SS 

M. ft. ling. 

IJ Sulphur precipitat. 

Beta naphthol aa 5i 

Balsam Peruv. 5ss 

Vaselini ^i 

M. 



^ 


Hydrargy: 


ri bichloridi 


gi'- 




Kerosene 


oil 








01. olivse 




aa 


5ss 




Alcoholis 




q.s. 


Siv 


M. 










^ 


01. Tiglii 






5i 




Sulphur p 


irecipitat. 




5ii 




Vaseline 






Bi 


M. 


ft. ung. 









Equal parts of oil of cade and castor oil have been recom- 
mended. 

Any one of these applications is to be used once daily, until 
an inflammatory reaction is obtained, when it is discontinued 
for a few days, and a simple ointment, as a 3 per cent boracic 
acid ointment applied until the reaction disappears, when the 
original ointment is again applied. 

For the intractable cases the X-rays have been recommended, 
with 10 to 15 minutes' exposure, static current and high vacuum 
tube are suggested as most beneficial. 

TINEA FAVOSA. 

Synonym. — Fa v us. 

Etiology. — This is a disease most freciuently affecting the 
scalp, due to a mould fungus, Achorion Schoenleinii, and is con- 
tagious. It usually begins in childhood, and most frequenth 



584 THE DISEASES OF CHILDREN. 

among the poor, especially in foreigners, Poles, Russians and 
Jews. The domestic pets may cause its dessemination. 

Pathology. — The epidermis, hair and hair follicles are in- 
volved. The crusts which form in favus are much thicker than 
in ringworm, it is cup-shaped, the sciitiilum, yellowish in color, 
and made up of mycelia and spores. The area beneath a seu- 
tulum is red, moist and free of hair. They have a peculiar odor. 

Symptoms. — The scalp is more often affected, and also areas 
of the body, and either may be affected alone. The occurrence 
of the favus cup or scutulum, the size of a split pea, the con- 
cave side up, usually with a hair in its center, is the first diag- 
nostic sign, and when dislodged leaves a moist, often bleeding 
area, slightly depressed, beneath. If the inflammation is exten- 
sive, the cups may coalesce. The hair looks dead, but is not as 
brittle as the hair in ringworm. Itching is usually present. 
Healed areas on the scalp show slightly depressed bald scars. 

Diagnosis is to be made from eczema and ringworm. It may 
be difficult to make a diagnosis from ringworm of the body if 
the characteristic lesion is not present in the scalp also. The 
scutula do not appear in any of the other diseases mentioned. 

Prognosis. — This is very unfavorable, as a cure is obtained 
with difficulty. 

Treatment. — The hair in the affected area must be pulled 
out after removing the scutula. Applications of a strong solu- 
tion of bicarbonate of soda will accomplish this. The scalp can 
be soaked with oil and the crusts scraped off. Epilation can 
proceed when the affected area is clean, and is a very tedi- 
ous process, as each hair must be carefully pulled out separately. 
Bulkley recommends the following stick for epilation : 



B 


Cerae flavae 


3ii 




Laccse in tabulas 


3iv 




Picis burgimdicse 


3x 




Gum mi damar 


5iss 


M. 


Moulded into stick. 





The end of the stick is melted and when warm applied to the 
hair and twisted off when cold. 

Any of the applications reconnnended for tenia tonsurans 



DISEASES OF THE SKIN. 585 

can be used to advantage in favus, followed by vigorous cleans- 
ing with green soap and water. 

In addition, the following can be used: 

3 Chrysarobin gr. xv to xx 

Vaseline '^i 

M. 

I?, Hydrargyri oleat. gr. x 

Vaseline 3^ 

M. 

I^ Pyrogallol 5 per cent. 

R, Acetic acid sprayed on the scalp in an atomizer. 

The X-rays may be used in intractable cases the same as in 
ringworm of the scalp. 

IMPETIGO CONTAGIOSA. 

Etiology. — Due to the invasion of the skin by the pus organ- 
isms, and it is common among the children of the poor. It is 
not infrequently epidemic in institutions, when it once obtains 
a start. Scratching in pruritus, scabies and pediculosis may 
cause it. 

Pathology. — The staphylococcus aureus is believed to be most 
regularly present, though Fox has described the finding of the 
streptococcus also. 

Symptoms. — The initial lesion is a vesicle, which quickly 
changes to a pustule, varying from the size of a pin head to a 
five-cent piece. The pustules rupture, their contents forming 
in a scab or crust. These can be removed, usually being at- 
tached to the hair, and leave a moist, bleeding area beneath. 
The pustules and the encrustations may coalesce, forming one 
large crust over the affected area. They are very superficial 
and leave no scars. 

The parts affected are chiefly the exposed parts of the body, 
and others may soon become affected by autoinoculation. The 
glands nearby may become enlarged. 

Diagnosis. — The very superficial character of the vesicles, 



586 THE DISEASES OP CHILDREN. 

pustules and crusts, and the evident inoculation of other parts, 
is enough for the diagnosis. It is to be diagnosed from pustu- 
lar eczema, pemphigus and varicella, and should be easy. 

Treatment. — The first indication is to remove the crusts. No 
medication will be of avail through these. Any oily substance 
will soften them, and they can be washed off with warm water 
and green soap. Bicarbonate of soda solution is helpful for this 
also. One of the following is then applied : 



R, Ichthyol ammon. 

Vaseline 
M. 


sulph 


3iss 
3i 


B Ung. hydrargyri ammon. clilor 

Vaseline 
M. 


. gr. V 
51 


IJ Hydrargyri clilor 

Vaseline 
M. 


idi mitis 


gr. V 
Si 


B Resorcin 

Ung. aquae rosae 




gr.x 
Bi 


IJ Acid boracic 
Vaseline 




gr.xx 

5i 



M. Sig. : Useful in the later stages. 

Vaccines may be found beneficial in intractable cases; the 
mixed stock, staphylococcus or autogenous vaccine may be used. 

PEMPHIGUS VULGARIS ACUTA. 

This is a rather rare condition in children. Duhring reports 
16 cases in 16,863 cases of skin disease. It is characterized by 
the development of bulljE or blebs, with more or less constitu- 
tional symptoms. 

Other varieties of pemphigus, even more rare, are described, 
viz., pemphigus vegetans and pemphigus foliaceus. 

Etiology. — Nothing is known definitely of the causation of 
this disease. There may be a connection between it and the 
nervous system. 

Pathology. — The blebs may involve all of the layers of the 



DISEASES OF THE SKIN. 587 

skin, or only the epidermis. The contents of the blisters is a 
straw-colored fluid, containing leucocytes, and an infiltration of 
the entire skin. There may be an infection of the bullae and 
absorption of toxic products. 

Symptoms. — Usually there are systemic symptoms preceding 
the development of the blebs, malaise, rigors or a chill, with a 
moderate rise of temperature. Slight pain or a stinging sensa- 
tion may be felt at the site of the developing bleb or bulla, or a 
macular spot may develop, followed at once by the blister upon 
it. The blisters vary from the size of a split pea to an area 
2 or 3 inches square. They have no areola. The bullae develop 
in successive crops for six or seven days, as a rule. The skin 
of all parts of the body is affected, rarely the mucous mem- 
branes. In one of the two cases reported, the blebs formed 
upon the conjunctiva. Cohen has described one case of this 
kind occurring in 50,000 eye cases. The duration of an attack 
is three or four weeks, or it may last months. 

When this disease develops in the new-born, or shortly after 
birth, it is designated pemphigus neonatorum. 

Diagnosis is from varicella, dermatitis herpetiformis, impetigo 
and erythema multiforme. 

The latter is much more acute, the lesions more limited, and 
there is an erythematous base. 

Prognosis. — These cases may result fatally, especially if they 
run a chronic course, when the system becomes much depleted. 
Hemorrhagic extravasation in the bullge is an unfavorable oc- 
currence. 

Treatment. — The bullae should be punctured, under aseptic 
precautions, and the loose skin removed. Mild antiseptic 
applications should be made to the raw surface below ; 5 per cent 
boracic acid ointment or 10 per cent ichthyol ointment. If the 
process is very extensive, the continuous bath treatment for sev- 
eral hours at a time is efficacious. 

Internal^, arsenic is of curative value. Fowler's solution 
in increasing doses, to the point of tolerance, is indicated. Qui- 
nin is also of benefit, in 2 to 5 grain doses, and iron in the stage 
of convalescence. Nourisliing food is also of value, and the diet 
should be closely watched. 



588 



THE DISEASES OF CHILDREN. 



The following cases occurred in my service at a local insti- 
tution, and it is through the courtesy of Dr. I. N. Bloom, derma- 
Boy, nine years old, in the institution four months. When three years 
old had a number of boils requiring incision. Vaccinated four weeks be- 
tologist, that they are reported : 




Fig. 100. — Pemphigus vulgaris acuta. 

fore with mild infection of site, but this had entirely healed 10 days pre- 
viously, and the scab was off. Admitted to the infirmary with a tempera- 
ture of 101.6° F., with a severe chill after admission. The following morn- 
ing there was a hyperemic blush on the left arm, extending from the point 
of vaccination to the tip of the shoulder. There was pain at this point 
during the night. At the upper border of this area there was a large bulla 
2 by 4 inches, which contained about 2 drachms of a transparent fluid. 
His tongue was coated a dirty Avliite and breath foul. By the next day a 
general bullous eruption had developed, 72 bullae being counted. All 
parts of the body were affected, but the chest and abdomen. The surface 
beneath the bullae was red and moist, having the appearance of a, scald. 
The nuicous membrane of the mouth was involved in the same process. 



DISEASES OF THE SKIN. 



589 



The left arm became involved almost over its entire extent, the palm of 
the hand on this side also being involved. It was very painful before 
the development of the bullse there. 

Epistaxis occurred on the fourth and fifth days. On the fifth day blebs 
developed on the left conjunctivae, with pain and photophobia. The scalp 
was involved on the seventh day by a number of bullae. 




Fig. 101. — Pemphigus. 

The temperature was fluctuating, rising before the development of each 
new crop of bullae. 

Eecovery occurred in three weeks. 

Girl, eight years old, rather poorly nourished, in Home seven weeks. In- 
vasion marked by a chill. Temperature chart accompanies report. Eleva- 
tion of temperature with each new crop of blebs. The largest bleb noticed 
was the result of coalescence of several, 3x3 inches, and held about 3 ounces 
of fluid. Blebs appeared without erythematous base, first on belly wall, 
and soon after on legs. The belly wall, genitals, legs, thighs, wrists and 
dorsal surfaces of hands were most affected. The upper arms and fore- 
arms were comparatively free. Scattered blebs on scalp, face, back, but- 
tocks and palms of hands and solos of feet. One bleb developed on hard 
palate. The base beneath the blebs was red and moist and did not bleed. 
Appetite was good, bowels regular. Was apathetic except when lesions 
were dressed. 



590 THE DISEASES OF CHILDREN. 

The disease lasted 23 days, with a slight relapse four weeks later. 

Fowler's solution was given internally, tub baths for temperature; re- 
moval of raised epidermis over the blisters, and raw surfaces covered with 
gauze spread with 5 per cent boracic acid vaseline ointment, this dressing 
confined by a bandage. 

ECZEMA. 

This is one of tlie most important of the skin lesions of child- 
hood, not only because of its prevalence but because of the variety 
of its manifestations and clinical types. Fully one-third of all 
skin diseases in children are eczema. 

Etiology. — Much discussion has been indulged in as to the 
cause of this disease, with the subject still unsettled. Bateman 
says of this disease: ''Eczema is a non-contagious eruption gen- 
erally the effect of an irritant, whether externally or internally 
applied, but occasionally produced by a great variety of irri- 
tants in persons whose skin is constitutionally very irritable." 
The constitutional causes are most important, of which disorders 
of the digestive system are most frequent. Chronic constipa- 
tion, catarrhal conditions of the gastrointestinal tract, toxemia 
from acute indigestion or intestinal putrefaction. Rheumatic 
diathesis and anemAa are also given as causes. Heredity plays 
an important role. The part the nervous system plays in the 
etiolog}^ is not well known, but that there is a connection is 
generally recognized. Dentition may be associated with a dis- 
tinct outbreak of eczema. 

Among the chemical and local causes are mustard, rhus, iodo- 
form, certain kinds of soap, dyes, exposure to cold, irritating 
effect of rough clothing, improperly washed napkins, etc. 

Pathology. — A few changes are common to practically all 
clinical types of eczema ; a dilatation of the blood vessels of the 
corium; an edema of the papillary layer; vesicles under the 
horny layer. Marked cellular infiltration occurs in the chronic 
form, and thickening of the skin. 

Symptoms. — Clinically, certain changes are practically com- 
mon to the several varieties. There is an erythematous ap- 
pearance of the skin, with formation on this of minute vesicles. 
With this there is a sense of burning or itching. The pruritus 
is specially prominent. There is a tendency of the vesicles to 
rupture with the formation of a moist surface, or one which 



DISEASES OF THE SKIN. 591 

is encrusted or scaly. The process is patchy in character and 
there is a tendency to frequent exacerbations and recurrences 
or relapses. 

Eczema may be acute, suhacute or chronic, and occur at any 
age. It is very frequent in childhood. Bulkley states that in 
3000 cases of eczema 676 occurred under the age of five years, 
and 520 of these were under three yars of age. 

It has a special predilection for the face, in many instances 
beginning upon the face. 

The following varieties of eczema may be recognized clinic- 
alty: Eczema erytliematosuni, papillosum, vesiculosum, pus- 
tulosum, squamosum. 

Eczema Erytliematosuni. — Occurs most frequently on the face, 
neck, hands and buttocks. As the name implies the first symp- 
toms are erythematous spots which quickly coalesce. AThen 
about the eyes there is edema of both lids. The skin is thick- 
ened, and is hot and dry. Itching and burning are severe. 
Moisture may be present if there is much scratching. As the 
inflammation subsides the swelling decreases and the surface is 
covered by small, branny scales. This form may become chronic. 

Eczema Papillosum. — This affects the back, arms, hands and 
legs most frequently. There is an eruption of dull red papules 
the size of a pin head, discrete or formed in small groups. These 
groups may coalesce and cover larger areas. The pruritus in 
this form is much greater than the others, and as a result of 
the scratching the tops of the papules are scraped off, leaving 
bleeding spots which become inflamed from infection. Recur- 
rence of this form is frequent. 

Eczema Vesiculosum. — This is the commonest form. The 
face, neck, hands and buttocks are oftenest affected. There are 
fine pin head size vesicles which develop on an erythematous 
base. Itching and burning precede the appearance of the ves- 
icles. These vesicles coalesce as the fluid in the skin forms, rup- 
ture, and the coagulation of the fluid forms a crust over the 
surface. New vesicles form at the margins, and the same process 
is repeated. 

The duration of the acute symptoms is about two weeks. If 
the crust is removed a moist, red base is uncovered. 



592 THE DISEASES OF CHILDREN. 

Eczema Fustulosum. — If an infection of the vesicular form 
of eczema takes place, the pustular form will follow. The early 
signs are the same as in the vesicular type. The crusts are 
much thicker, and yellow or greenish in color. It is most often 
seen on the face and head. The early burning and itching may 
be present, but it is less marked after the pustules form. 

Eczema Squamosum may be a primary condition or any of 
the types preceding may pass through the squamous or scaly 
stage before complete recovery. The skin is dry and covered 
with a fine scale. This is the selorrJwic form, and occurs most 
often on the scalp of the child, often behind the ears and the 
eyebrows. When on the scalp it is the ' ' milk crust ' ' of the laity. 
A dirty yellow crust covers the scalp, and if it has been untreated 
sometimes is quite thick. 

Prognosis. — Because of its proneness to recur, the prognosis 
as to a cure is not very favorable. The earlier treatment is be- 
gun the more chance for a prompt cure. Chronic cases respond 
slowly. 

Treatment. — Attention to the general health of the child is 
indicated, its habits, food, bowels, kidneys, exercise, clothing, 
bathing, sleep, etc. Every detail of its life should be minutely 
ascertained as often a trivial cause will be found which is re- 
sponsible for the condition. 

Not many internal remedies have been found of service. Ar- 
senic is of doubtful value. Wine of antimony in 5 minim doses 
has been recommended. Turpentine in small doses has been rec- 
ommended by Crocker. 

The child should not be allowed to scratch the inflamed area. 
This can be prevented by pinning the hands down to its dress, 
a rather unnatural method ; by tying them in small canton flannel 
bags, or special metal hand coverings, and by having the child 
wear a mask made of thin muslin, with eyes, mouth and nose 
uncovered. Soap and water should be kept off the affected areas 
entirely. No local remedy will be of avail if an attempt is made 
to apply it through the crusts. The crusts must be softened by 
the application of olive oil or soda solution and removed by a 
forceps. 

Among the indications present are applications of soothing 



DISEASES OF THE SKIN. 593 

remedies in the acutely inflamed cases, when the vesicles form, 
applying astringent remedies. Locally, a large number of reme- 
dies have been suggested, evidence sufficient to decide that none 
is effective in all cases. Lotions, ointments and powders are the 
forms in which remedies are applied externally. 

In the acute form of eczema with burning and itching, any 
bland application is of benefit as lead and opium wash ; biborate 
of soda solution, oi to Oi, sopped or poured on several times a 
day. In the vesicular form, dusting powders are helpful ; tal- 
cum, starch, magnesium carbonate, stearate of zinc, etc. Las- 
sar's paste is of benefit as a bland and unirritating application. 

The following applications are recommended : 



IJ Tinct. picis Hquidse 


Si 


Acidi phenici 




gr. xl 


Glycerine 




3iss 


Zinci oxidi 




3ii 


Ext. hamamelis dest. 


3i- 


M. 


q.s. ad 


5vi 
( Schamberg. ) 


I^ Zinci oxidi 






Amyli 




3ii 


Vaseline 




3ss 


M. ft. paste. 






IJ Zinci oxidi 




Bss 


Pulv. calamine 


prep. 


3iv. 


Glycerine 




5i 


Aq. calcis 




3viii 


M. 




(Startin.) 



In the chronic form several drugs are of value, viz., tar, resor- 
cin, salicylic acid, gelatin, chrysarobin, sulphur, iehthyol, silver 
nitrate, diachylon ointment, oil of cade, etc., and can be combined 
in many formulae. 

HERPES. 

Synonyms. — Fever blister. Cold sore. 

Definition. — A collection of vesicles upon the skin upon a 
common reddened base. They may occur upon the face, herpes 



594 THE DISEASES OF CHILDREN". 

facialis; upon the lips, herpes lahialis; "apon the genitals, her- 
pes genitalis; upon the body, herpes zoster. 

Symptoms. — This eruption may occur independently or in 
connection with various febrile disorders, as pneumonia, tonsil- 
litis, acute ''colds," cerebrospinal meningitis, etc. 

The first symptom is a sense of burning and swelling, fol- 
lowed by a reddened base, and shortly by the crop of small 
vesicles, pin head in size or larger. The vesicles may rupture 
and form crusts. Successive crops may develop for several days, 
and there is a tendency for them to recur. 

Diagnosis. — From eczema and impetigo. The latter, with 
great rarity, occur in single patches. 

Treatment. — No special treatment is required. The diges- 
tion must be watched, the diet regulated and the bowels put in 
good condition. In recurrent cases, arsenic is of value. Locally, 
when the first symptom is noticed, the application of camphor 
or tincture of myrrh is of service; as soon as the vesicles have 
ruptured, dry calomel applied will be of service, or an ointment 
of calomel and vaseline, gr. x to §i, or 5 per cent boracic acid 
ointment. 

HERPES ZOSTER. 

Synonym. — Shingles. 

Definition. — An acute inflammatory condition of the skin 
characterized by the formation of vesicles, distributed along the 
course of the cutaneous nerves, and accompanied by neuralgic 
pains. A comparatively rare condition in young children. 

Etiology. — Season plays a part in etiology, it occurring more 
frequently in winter and spring. Exposure to cold is also a 
cause. There seems to be an intimate relationship between the 
lesion in the skin and the change in the nerve trunk, possibly an 
interstitial neuritis of the peripheral nerves, or of the sensory 
ganglia of the posterior nerve roots. 

Symptoms. — After a brief period in which sharp, burning 
neuralgic pains are felt over the region affected, successive 
crops of vesicles appear, following the course of the nerve 
involved. Papules and macules precede the vesicular stage a 
very short time. As a rule but one side is affected at a time. 



DISEASES OF THE SKIN. 595 

The most frequent parts affected are the areas supplied by the 
intercostal and trifacial nerves. Some fever may attend the for- 
mation of the vesicles. 

Diagnosis. — Any vesicular eruption occurring upon one side 
of the body and following fairly accurately the course of a per- 
ipheral nerve is difficult to mistake for any other disease. 

Treatment. — Protection of the eruption from injury or in- 
fection is the first indication. It may be painted with tincture 
of benzoin, or an ichthyol collodion dressing, 5i to §1, or an 
ichthyol ointment can be used. 

Internally sedatives may be necessary for the pain, heroin or 
codeine. 

Quinin and arsenic are useful through the course of the 
disease. 

The application of the galvanic current is most beneficial. 

PRURITUS. 

In this condition there is no special pathology except that 
produced by the irritation due to scratching. Itching, however, 
is a prominent symptom of a number of the skin diseases of 
children; urticaria, scabies, eczema, sudamina, pediculods, etc. 
It also occurs at the anus, pruritus ani, as a result of intestinal 
worms. 

An itching of the skin is evidenced by restlessness in the 
very young, disturbed sleep, and rubbing with hands and feet. 
The itching is usually intensified when the child is undressed, 
caused by the air striking the skin. As a result of the scratch- 
ing the skin may become infected and an impetigo result. Much 
infiltration of the skin results from long-continued scratching. 

An underlying general or systemic condition may be the cause 
of the condition acting through the nervous system, especially 
the cutaneous nerves. 

Treatment. — If possible, the diagnosis must be made giving 
appropriate treatment to the cause found. Internally, tonics 
and nerve sedatives are of vahie ; locally, the antipruritic rem- 
edies afford temporary relief. Bathing in a strong solution of 
bicarbonate of soda, or a solution of starch, allowed to dry on 
the skin, and ointments containing any of the following, or a 



596 THE DISEASES OF CHILDREN. 

combination of them, will prove effective; camphor, menthol, 
chloral, acid carbolic, liquor potassge, thymol, etc. 

URTICARIA. 

Synonyms. — Nettle rash, hives, lichen urticatus. 

A number of varieties may occur, urticaria factitia, urticaria 
papulosa (lichen urticatus), urticaria tuherosa, urticaria hemor- 
rhagica, urticaria hidlosa. 

Etiology. — This is generally considered as a cutaneous man- 
ifestation of a gastrointestinal disorder with a resulting toxemia, 
and either food or drugs may cause the same conditions. One 
family under my observation is peculiarly susceptible to quinin, 
it producing a general urticaria in four members; one cannot 
eat ripe fruit, berries or peaches without a severe case of urti- 
caria, etc. The antitoxic sera, before their purification and elim- 
ination of the globulins from them, frequently caused both a 
local and general urticarial rash. 

Pathology. — The process is most likely an angioneurosis. 
The process, as outlined, may be papular, vesicular or bullous in 
character. 

Symptoms. — The eruption appears suddenly and without 
warning, the most common variety appearing as raised papules 
or wheals of various sizes, with whitish tops and a red base. 
These are accompanied by a sense of burning and severe itching. 
They may be localized or the whole body may be affected. In 
the urticaria factitia, letters can be traced on the skin, and they 
will stand out in bold relief in a few minutes. The name der- 
7nographism has been given to this phenomenon. 

The form in which large wheals appear is usually of short 
duration, the fine papular form may last a number of weeks. 

Prognosis. — The chronic form of urticaria is very unprom- 
ising, and fortunately is comparatively rare in children. The 
acute form is quickly recovered from, but has a tendency to 
recur. 

Treatment. — In the acute cases, a brisk purgative is of bene- 
fit, and careful regulation of the diet will assist in the cure and 
prevent a recurrence. Inquiry as to special articles of diet 
should be made, in an effort to trace the direct cause of dis- 



DISEASES OF THE SKIN. 597 

agreement. Milk of magnesia is a good remedy to correct the 
acidity as well as for its laxative effect. 

Locally, the application of a hot bicarbonate of soda solution 
or a general bath containing the soda, is of benefit. The fol- 
lowing lotion is recommended by Schamberg : 



H Menthol. 


gr. XXX 


Acidi phenici 


f3i 


Tinct. picis mineralis 


3i-ii 


Ext. hamamelis dest. 


5i 


Zinci oxidi 


3ii 


Glycerin! 


3ii 


Spt. vini rect. 


3ii 


Aquae camphorse 


Sii 


Aquae dest. q.s. ad 
M. 


Jviii 


PSORIASIS. 





This is not an uncommon condition in childhood. It is evi- 
denced by irregular patches with sharp cut edges, the center 
covered with whitish scales. They are found most often on the 
extensor surfaces of the extremities, later perhaps, on the fore- 
head, scalp, and trunk. 

This condition has a tendency to disappear during the summer 
months, recurring in winter. It is rather intractable to treat- 
ment. Eemoval of the scales, application of a 2 per cent oint- 
ment of chrysarobin will prove of benefit. 



APPENDIX. 

MILK MODIFICATIONS. 

Mathematical equations are the basis of the majority of meth- 
ods for the modification of milk, and one of these should be 
selected by the physician, memorized and used. 

The following are some of the most practical which have been 
suggested. 

BANER'S METHOD. 

The method devised by Baner is probably the most useful 
and practical; it is as follows: Determine the quantity to be 
fed in 24 hours and the percentage of the ingredients, and use 
the following formula : 

Q = quantity in 24 hours ; C = cream in ounces. ( In the 
following equation if a 20 per cent cream is used, 16 will be 
the divisor ; if a 16 per cent cream is used, 12 will be the divisor ; 
and if a 12 per cent cream is used, 8 will be the divisor.) 
M = whole milk in ounces ; F = percentage of fat in the mix- 
ture; P = the proteids, and L (lactose) =dry sugar of milk in 
ounces : 

QX (F — P) 

= (if 12 per cent cream is used.) 

8 

M = C 

4 (i.e., the proteids in cow's milk.) 

(L — P) XQ 



( result being in ounces ) 



100 



Let 20 ounces be the quantity to be fed in 24 hours (10 feed- 

598 



APPENDIX. 599 



ings of 2 ounces each) and the formula be: Fat, 2 per cent; 
sugar, 6 per cent; proteids, 1 per cent; the equation will be as 
follows : 



20 X (2 — 1) 20 



20X1 
Mc=i 2i = 5 — 21 = 21 oz. 

4 

W = 20 — ( ii+ 2-J- ) « 20 — 5-= 15 oz. 

(6—1) X20 5 x20 100 

M. S. — = =. =1 oz. 

100 100 100 

Ordinary gravity cream contains 16 per cent of butter fat, 
and if 2 parts of this are added to 1 part of milk (containing 4 
per cent fat), 12 per cent cream will be obtained. 

Westcott has also devised mathematical formulae for calcu- 
lating milk mixtures as follows : 

C = cream in ounces ; M = whole milk in ounces ; F = fat ; 
P ^ proteids ; L = lactose, sugar of milk, dry in ounces ; Q = 
total quantity ; S ^ sugar percentage : 

[F — F) Q 

C= 

8.2 (12 p. c. cream) or 12.4 (16 p. c. cream) or 16.8 (20 p. c. cream) 

QF 

J/= 3C (12p. c.) or 4C (16 p. c.) or oC (20 p. c.) 

4 

(?*S' — 4.3 (M -\-C). 

L= • 

100 

If a 20 ounce mixture is desired, containing 3 per cent of 
fat, 6 per cent of sugar, and 2 per cent of proteids, using 16 
per cent cream, the formula would read : 



(3 — 2) 20 20 
= =1.6 oz. 



12.4 12.4 



600 THE DISEASES OF CHILDREN. 

20X3 
M= (4 X 1.6) =15 — 6.4 = 8.6 oz. 



20x6 — 4.3(8.6 + 16) 120 — 43.9 

L = = = 0.76 oz. « I oz. 

100 100 

Conversely, in order to determine the percentage of ingredi- 
ents in any combination of cream, milk and sugar, Westcott 
suggests the following : 

To find the percentage of fat : 

^' 

— X 16 (or 12) = fat percentage from cream. 

Q 

M 

— X 4 1^' fat percentage from milk. 

Q 

Sum of these = fat percentage in mixture. 
To find the percentage of proteids : 

C 

— X 3-6 (16 p. c.) or 3.8 (12 p. c.) = proteid percentage from cream. 

M 

— X 4 = proteid percentage from milk. 
Q 

Sum of these = proteid percentage in mixture. 

lOOL + 4.3 (M + C) 
Sugar percentage = 

Q 

An illustration : Take the above mixture, 1.6 ounces of 16 per 
cent cream, 8.6 ounces of milk, % ounce of lactose, and 191/^ 
ounces of water: 

1.6 

X 16 = 1-28 per cent fat from cream. 

20 

8.6 

X 4 zz: 1.72 per cent fat from milk. 

20 

1.28 -|- 1.72 = 3.0 total per cent fat in mixture. 

1.6 

X 3.6 = 0.28 proteid per cent from cream. 

20 



8.6 



20 



APPENDIX. 



1.72 proteid per cent from milk. 



601 



0.28+ 1.72 = 2.00 total proteids in mixture. 
100 X 0.76 + 4.3x10-2 76 + 43.9 



20 



20 



6 per cent sugar. 



"\Yescott has also devised a scale on cardboard discs which 
show the amount of each ingredient to use. 





■^ %•> 


^~"^ 










^\ 




\ 


f '.•„ 


Ny 




\ '■' 


:7/ 


/ '» \ 
^^^^ - \ 


2 £ 












^ if '' / 


\ 


-M 


\ 


/ 


^ 






^ 



Fig. 102. — Westcott's milk modification chart. 

Hamilton's method is based on the fact that cream, milk 
and skimmed milk contain relatively the same amount of pro- 
teids and salts : 

Multiply quantity of the mixture by the percentage of fat 
desired and divide by the percentage of cream used, the quo- 
tient equals the amount of cream. 

Multiply the quantity of milk mixture by the percentage of 
proteids desired, and divide by 4, the percentage of proteids in 
skimmed milk ; subtract from this the amount of cream to be 
used, the result equals the amount of skimmed milk. 

The quantity of cream and skimmed milk subtracted from 



602 



THE DISEASES OF CHILDREN. 



the total quantity gives the amount of diluent. Three drachms 
of lactose must be added to each 10 ounces of the mixture. 

Example. — Forty ounces of mixture desired, of the following 
formula : Fat, 4 ; sugar, 7 ; proteids, 2 ; 16 per cent cream. 

40 X 4 -:- 16 = 10 ounces of 16 per cent cream. 

40 X 2 -:- 4 — 20 — 10 = 10 ounces of skimmed milk. 

40 — 20 = 20 ounces of diluent. 

Sugar = 4 level tablespoonfuls. 

Lime water, q. s. 



CONNOR S TABLE. 

The following is Connor's table for milk modification 



ogg 






















O ^ P 








PER CENT FAT. 








Is 


h 


2 ^ ^ 


















w « 


H M 


odg 


















ftS 


PU 


£^5 


































^ 


-fj 




'S 












1=1 


a 


"S 


S 


!=J 


a 


P^ 


P- 






"5 


o 


8-^ 






«^ 


ffi,-^ 


o 


s 


_o 






^ 


cS 


s-^ 


53^" 




'SM 


li 




o 


o 






03 






ra 


oa 


ra 


aa 


















- (U 




r^ 0) 


tH <— < 


...S 


.2 " 


rS PI 






Tl 


J4 


il 


H'o 


-i-T O 


^'O 


o 


1s"2 


^q; 




s 






1^ 


T M 

o J 


ii 


iHHiN 


§a 


ga 

00 H^ 


^ a 


a^. 

gco 




CO 


-*2 


"r3 

0.L3 


-ti ft 




,(M 


.(M 


..CO 


..CO 


f 


"'.'73 


Ti 

fe 




CM 

7 










o 




l« 




0.50 


0.75 


1.00 


1.25 


1.50 


1.75 


2.00 


0.41 


0.50 







0.14 


0.57 


0.86 


1.14 


1.43 


1.71 


2.00 


2.30 


46 


0.57 




5 


0.17 


0.67 


1.00 


1.33 


1.67 


2.00 


2.34 


2.67 


0.54 


0.67 




4 


0.20 


0.80 


1.20 


1.60 


2.00 


2.40 


2.80 


3.20 


0.65 


0.80 




3 


0.25 


. 1 .00 


1.50 


2.00 


2.50 


3.00 


3.50 


4.00 


0.81 


1.00 




2 


0..33 


1.33 


2.00 


2.67 


3.33 


4.00 


4.66 


5.33 


1.08 


1.33 


9 


;j 


0.40 


1.60 


2.40 


3.20 


4.00 


4.80 


5.60 


6.40 


1.30 


1.60 




1 


0.50 


2.00 


3.00 


4.00 


5.00 


6.00 


7.00 


8.00 


1.63 


2.00 


5 


:^ 


0.62 


2.50 


3.75 


5.00 


6.25 


7.50 


8.75 


10.00 


2.03 


2.50 


9 


1 


').r,7 


2.67 


4.00 


5.33 


6.67 


8.00 


9.33 


10.67 


2.16 


2.67 




1 


0.75 


3.00 


4.50 


6.00 


7.50 


9.00 


10.50 


12.00 


2.44 


3.00 



MILK MODIFIERS. 

Several modifiers of milk have been introduced, the Haas' 



APPENDIX. 



603 



Materna, the Deming- IModifier and Sloane i\Iateriiity ]\Iilk Set. 
The Materna is a 16 ounce glass graduate with pouring tip. 
The outer surface is divided into seven panels. One of these 
shows the ounce graduation, the other six show as many 
formula^, so arranged as to be suitable for the entire first year's 
feeding. Having determined on the formula desired, the 
respective ingredients are poured into the graduate to the line 
designated for the substance then inserted. First, the milk 
sugar is put in, then warm water or whatever diluent is deter- 



O'V 





Fig. 103. — Haas' Materna. 



Fig. 104. — Deming Modifier, 



mined upon, in which this is dissolved, the lime water, the 
cream and then the milk; the ingredients are then thoroughly 
stirred, and resultant mixture should analyze the same as the 
formula at the top of the panel used, 16 per cent or gravity 
cream and whole milk are used in the mixture. Enough bottles 
for the 24 hours are filled to the required amount, stopped with 
absorbent cotton, kept on ice, and each bottle warmed to blood 
heat when used. The following are the markings on the panels 
of the Materna: 



604 



THE DISEASES OF CHILDREN. 



1 


2 


3 


4 


5 


6 


Fat, 2% 

Proteids, 0.6% 

Sugar, 6% 

MILK 


Fat, 2^% 

Proteids, 1% 

Sugar, 6% 

MILK 


Fat, 3% 

Proteids, 1% 

Sugar, 6% 

MILK 


Fat, 3i% 

Proteids, 1*% 

Sugar, 7% 

MILK 


Fat, 4% 

Proteids, 2% 

Sugar, 7% 

MILK 


Fat, 3Wc 

Proteids, 2^% 

Sugar, SWo 

MILK 


Cream 


Cream 


Cream 


Cream 


Cream 




. 






Lime-water 




Lime-water 


Lime-water 










Water 






Lime-water 




Water 


Water 










Milk-sugar 






Milk-sugar 






Water 


Lime-water 






Water 


Cream 




Milk-sugar 








Milk-sugar 


Barley gruel 






Milk-sugar 




Gr. sugar 














X 


X 


X 


X 


X 









The Deming percentage milk modifier is a 16 ounce grad- 
uate, its graduations and percentages being based on whole 
and top milks containing 3.2 per cent proteids and 4 per cent, 
7 per cent, 10 per cent and 12 per cent fat: 

Directions. — Look in the column headed proteids for desired 
percentage of proteids. Then move to the right until the 
desired percentage of fat is found in line with the percentage 



APPENDIX. 
GRADUATIONS AND MARKINGS. 



605 



OUNCES. 


PROTEIDS. 

Top line. 


FAT 


16 






Use 


Use 


Use 




Use 


7 p.c. milk or 


10 p.c. milk or 


12 p.c. milk or 






4 p.c. milk or 


the top 16 oz. 


the top 11 oz. 


the top 9 oz. 


14 




whole milk. 


from one 


from one 


from one 








quart. 


quart. 


quart. 




per cent. 


per cent. 


per cent. 


per cent. 


per cent. 


12 


2.4 


■ 3.0 


5.2 


7.5 


9.0 




2.2 


2.7 


4.8 


6.8 


8.2 


10 


2.0 


2.5 


4.4 


6.2 


7.5 




1.8 


2.2 


3.9 


5.6 


6.7 


8 


1.6 


2.0 


3.5 


5.0 


6.0 




1.4 


1.7 


3.0 


4.3 


5.2 


6 


1.2 


1.5 


2.6 


3.7 


4.5 




1.0 


1.2 


2.2 


3.1 


3.7 


4 


.80 


1.0 


1.7 


2.5 


3.0 




.60 


.75 


1.3 


1.8 


2.2 


2 


.40 


.50 


.88 


1.3 


1.5 


1 


.20 , 


.25 


.44 


.62 


.75 



of proteids. Now look at the head of this fat column to find 
what strength of milk to use. Pour this milk into the modifier 
up to the desired percentage of proteids and add gruel or water 
to "top line." This will make 16 ounces. 

The percentage of sugar in the mixture will be almost exactly 
the same as the percentage of proteids : 

1 level tablespoonful of granulated sugar adds 2i/2%. 

2 level tablespoonfuls of granulated sugar add 5 %. 
11/2 level tablespoonfuls of milk sugar add 2i/2%. 

3 level tablespoonfuls of milk sugar add 5 %. 
Slide a knife over the bowl of the spoon to make it level full. 
Example. — To make a mixture 3 per cent fat, 6 per cent 

sugar and 1 per cent proteids, look in the proteid column for 
1 per cent. At the right of this will be found 3.1 per cent in 
the third column of fat percentages, which is headed: "Use 
10 per cent milk or the top 11 ozs. from 1 qt." Obtain 1 quart 
of good, fresh milk, and when the cream shows plainly dip off 
the top 11 ounces into a pitcher or bowl, and stir to mix. The 
first dipperful will have to be removed with a teaspoon or the 
bottle will overflow when the dipper is inserted. Pour this 
milk into the modifier up to the 1 per cent proteids line. Then 
fill with gruel or water to "top line." Add 5 per cent sugar — 



606 THE DISEASES OF CHILDREN. 

2 level tablespoonfuls of granulated sugar or 3 of milk sugar — 
and stir to dissolve the sugar. To add 5 per cent or 10 per cent 
of lime water to the mixture, leave out 1 ounce of gruel or water 
for 5 per cent or 2 ounces for 10 per cent, and replace with 
lime water. 

After the cream has risen on a quart of 4 per cent milk, there 
may be dipped from the top 7 ounces, 16 per cent fat ; 8 ounces, 
14 per cent; 9 ounces, 12 per cent; 10 ounces, 11 per cent; 11 
ounces, 10 per cent; 13 ounces, 9 per cent; 15 ounces, 8 per 
cent; 16 ounces, 7 per cent; 20 ounces, 6 per cent; 24 ounces, 
5 per cent; for 4 per cent milk or whole milk shake the bottle 
to mix the cream and milk; to obtain fat-free milk dip off the 
cream and use the remaining milk. 

As the modifier is marked, 50 combinations of fat under 4 
per cent may be had with proteids below 2 per cent, and 36 
with proteids below 1 per cent. But by using the above-men- 
tioned milks 12 different percentages of fat may be had with 
each percentage of proteids. When half graduations are used 
proteids may be varied by .10 per cent, and fat by .12 per cent, 
.15 per cent, .19 per cent, .22 per cent, .25 per cent, .31 per' 
cent, .35 per cent, .38 per cent, .44 per cent or .50 per cent, at 
a time, giving over 200 hundred combinations of fats and 
proteids. 

The Sloane Modifier, Cragin's method, consists of a glass 
holding 20 ounces, and Chapin's Cream Dipper, holding 1 
fluid ounce. The following directions are given for the use 
of this modifier : 

From the upper part of a quart bottle which has stood four 
hours are obtained two kinds of top milk : 

Top Milk No. 1. — Obtained by taking 10 dipperfuls from 
the top of the bottle, the first dipper being filled with a spoon 
to prevent spilling, the remaining 9 dipperfuls being taken 
by dip[)ing carefully from the bottle. These 10 dipperfuls are 
to b(^ mixed in a clean pitcher, and from the milk thus mixed 
tlic baby's food inn\' be pi'cpni'cd iiiilil it is from four to six 
luonlhs old. 

'I\)|) Milk No. 2. — ()])1niii('(l by taking 1(5 di|)perfuls fi'om the 
top of llic bottle, Ihc firsi dipper being filled ns befoi'e with a 



APPENDIX. 



607 



spoon, the remaining 15 dipperfnls being taken by dipping 
carefully from the bottle. 

These 16 dipperfnls are to be mixed in a clean pitcher, and 
from the milk thus mixed the baby's food may be prepared 
from the age of about four months until it is a year old. 

In using this milk set, whatever strength of food is desired, 
the sugar and the lime water are always the same : 1 ounce of 
milk sugar (or I/2 ounce of granulated sugar) and 1 ounce (1 
dipperful) of lime water. 

The quantity of food made by filling the glass once is always 
the same — 20 ounces. The strength of the food varies with 
the number of dipperfuls of top milk used. 

Preparation of the Food. — First, into the measuring glass 
pour milk sugar up to the line marked 1 ounce milk sugar, or 
granulated sugar up to the line marked one-half ounce granu- 
lated sugar. 

Second. — Add 1 dipperful of lime water and mix by shaking 
the glass. 

Third. — Add the required number of dipperfuls of top milk, 
according to the age of the baby, as explained below. 

Fourth. — Fill the measuring glass up to the line marked 20 
ounces of food with water, either plain or barley water or oat- 
meal water. 



Age of infant. 



1 week 


2 


2 weeks 


2 


4 weeks 


2 


6 weeks 


2.^ 


8 weeks 


2^ 


3 months .... 


2^ 


4 months .... 


2J 


5 months .... 


3 


months .... 


3 


7 months 


3 


8 months .... 


3 


i) months .... 


3 


10 months .... 


3 


11 months .... 


3 


12 months .... 


3 



Interval i No. of feed- 
in j ings in 
hours. 1 24 hours. 



10 
10 
9 
8 
8 
7 
7 
6 
() 
G 
() 
6 
5 
5 
5 



No. of Amount 

night ounces at 

feedings, each feedini 



1 

2-1 
3^ 

4 

4J 
5^ 
H 

H 

7 

7 

8.\ 

8^ 

<) 



Total 

amount 

ounces in 

24 hours. 



10 

15 

22* 

24 

26 

28 

3U 

33 

34i 

37.\ 

42 

42 

42. \ 

43^ 

45 



608 THE DISEASES OF CHILDREN. 

Formula on which the Average Healthy Baby may be started; 

Premature No. 1 or 2 

2-4 weeks No. 5, 8, 9, or 11 

1-2 months No. 12 or 13 

2-4 months No. 19 or 20 

4-6 months No. 24 or 25 

6-8 months No. 26 or 27 

8-9 months No. 28 



TABLE FOR ESTIMATION OF FAT PERCENTAGES IN CREAMS. 

One quart of whole milk, of 4 per cent fat, will yield on an average 
approximately : 

Cream 10 per cent in the upper 8 oz. after 6 hours. 

Cream 10 per cent in the upper 11 oz. after 8 to 12 hours. 

Cream 12 per cent in the upper 8 oz. after 8 hours. 

Cream 16 per cent in the upper 6 oz. after 8 hours. 

Cream . 20 per cent in the upper 4 oz. after 4 to 6 hours. 



WHEY CREAM MIXTURES. 

Whey cream mixtures may be obtained by using whey as a diluent, in 
place of the boiling water, preferably in the combinations containing low 
proteid percentages. Each 2 ounces of whey replacing an equal quantity 
of water in a twenty-ounce mixture, will raise the whey proteid percentage 
0.10, and will increase the sugar percentage 0.50. The total sugar percent- 
age is, therefore, the amount contributed by the cream and fat-free milk, 
which is indicated in the last column of the table on the reverse of the 
card, plus that of the whey. The amount of dry sugar which must be 
added to make the desired final sugar percentage can be easily calculated 
by reference to the following table: 

1 measure of dry lactose in a 20-oz. mixture gives 2.00 per cent of sugar. 

^ measure of dry lactose in a 20-oz. mixture gives 1.00 per cent of sugar. 

I measure of dry lactose in a 20-oz. mixture gives 0.50 per cent of sugar. 

(One measure is approximately one level tablespoonful. ) 

Example — If in formula 21 fourteen ounces of whey are added in place of 
the same quantity of water, the whey proteids are increased 0.70 per cent, 
making total proteids of 1.30 per cent. The sugar contributed by the 
cream is 0.78, by the whey 3.50, making a total of 4.28. The desired per- 
centage of sugar is 6, therefore the balance of 1.72 per cent may be obtained 
by adding a little short of one measure of sugar. 

Whey should be made of fat-free milk, and should be heated to 150° F. 
(65° C.) before it is added to the cream mixture, to destroy the rennet 
enzyme. One quart of fat-free milk will yield about 24 ounces of whey. 



APPENDIX. 



609 



During the first month it is usually better to use plain water, 
after that barley water, or if the baby is very constipated, oat- 
meal water. 



MODIFICATION OF MILK LADD'S TABLE 





TWENTY-OUNCE MIX- 


OUNCES OF 


OUNCES OF FAT- 
FREE MILK USED 
WITH CREAMS OF 


OUNCES 




^ 




TURES, PERCENTAGE OF 




CREAM 


OF 


i 


■^ 




























II 




























u 


u 


a 




























-2 


^ 


u 


<u >, 


NO. 


Fat. 


Sugar 


3 




w 


«i 


« 


w 


«' 


u 


w 


<i 
















° 


"ci 


?i, 


si. 


d 


si 


si 


A 


si. 


si 


a 


a; 


r^ 


53° 










^ 


o 


(M 


?o 


o 


c> 


(X» 


<© 


o 


3 


'o 


1 


bD 








fM 


< 




I** 




** 


T-K 


i~( 


TH 


<^» 


P5 


^ 










5 


* 


* 


* 


14 


* 


* 


* 





7 


174 


2 




1 


1.50 


4.50 


0.25 


0.33 


2 


1.50 


4.50 


0.50 


5 


3 


2i 


2 


14 





I 


1 


14 




16 


2 


0.61 


3 


2.00 


5.00 


0.25 


5 


* 


* 


* 


2 


* 


* 


* 







17 


2i 


0.75 


4 


2.00 


5.00 


0.50 


5 


* 


3i 


2* 


2 


4 





4 


1 




151 


2i 


0.73 


5 


2.00 


5.00 


0.75 


5 


4 


3;: 


2i 


2 


1 


14 


2i 


2x 




144 


2 


i.ni 


6 


2.00 


5.50 


1.00 


5 


4 


3^ 


2-. 


2 


If 


24 


3i 


3i 




13i 


2i 


1.30 


7 


2.50 


6.00 


0.50 


5 


* 


* 


3i 


25 
2^ 


* 


* 





f 




15f 


2i 


0.73 


8 


2.55 


6.00 


0.75 


5 


* 


4;' 


3:- 


* 


i 


li 


2 




144 


2i 


1.01 


9 


2.50 


6.00 


1.00 


5 


5 


4r 


3^ 


24 


1 


}i 


2- 


34 




13* 


2* 


1.23 


10 


3.00 


6.00 


0.50 


5 


* 


* 


3i 


3 


* 







J 




15i 


24 


0.84 


11 


3.00 


6.00 


0.75 


5 


* 


* 


3i 


3 


* 





li 


2 




14 


24 


1.12 


12 


3.00 


6.00 


1.00 


5 


6 


5 


3; 


3 





1 


2i 


3 




13 


2i 


1.35 


13 


3.00 


6.00 


1.25 


5 


6 


5 


3; 


3 


li 


2i 


3* 


4i 




llf 


24 


1.35 


14 


3.00 


6.50 


1.50 


5 


6 


5 


31 


3 


t-n 


34 


4J 


54 




104 


2i 


1.91 


15 


3.00 


6.50 


2.00 


5 


6 


5 


St 


3 


5| 


6^ 


7f 


84 




74 


2 


2.68 


16 


3.50 


6.00 


0.50 


5 


* 


* 


* 


34 
3* 


* 


* 


* 







154 


2* 


0.78 


17 


3.50 


6.00 


0.75 


5 


* 


* 


4^ 


* 


* 





1 




144 


2* 


1.01 


18 


3.50 


6.50 


1.00 


5 


* 


51 


4i 


34 


* 





li 


2i 




13i 


22 


1.26 


19 


3.50 


6.50 


1.25 


5 


7 


5f 


4* 


34 


i 


It 


3 


4 




11* 


2. 


1.68 


20 


3.50 


6.50 


1.50 


5 


7 


5J 


4| 


34 


2' 


3-i 


44 


54 




10 


Oi 


2.02 


21 


4.00 


6.00 


0.60 


5 


* 


* 


* 


4 


* 


* 









15 


2* 


0.78 


22 


4.00 


6.00 


0.75 


5 


* 


* 


5 


4 


* 


* 





1 




14 


2* 


1.12 


23 


4.00 


7.00 


1.00 


5 


* 


* 


5 


4 


* 


* 


1 


2 




13 


2f 


1.35 


24 


4.00 


7.00 


1.25 


5 


* 


6t 


5 


4 


* 


% 


2* 


34 




11* 


2* 


1.68 


25 


4.00 


7.00 


1.50 


5 


8 


6f 


5 


4 


1 


2-1 


44 


5 




10 


2* 


2.02 


26 


4.00 


7.00 


2.00 


5 


8 


6t 


5 


4 


3i 


4f 


64 


74 




7* 


2i 


2.56 


27 


4.00 


7.00 


2.50 


5 


8 


61 


5 


4 


6i 


74 


9i 


lOi 




4=z 


2 


3.20 


28 


4.00 


7.00 


3.00 


5 


8 


6t 


5 


4 


^i 


104 


12i 


13t 




If 


1* 


3.88 


29 


4.00 


6.00 


3.00 


5 


8 


6t 


5 


4 


5^:- 


10* 


12i 


13i 




If 


1 


3.88 


30 


4.00 


5.50 


3.00 


5 


8 


6j 


5 


4 


93 


10* 


121 


13i 




If 


f 


3.88 



Combination impossible with percentages of cream indicated. 

For 25-ounce mixtures multiply the amount of each ingredient by li. 
For 30-ounce mixtures multiply the amount of each ingredient by 1*. 
For 35-ounce mixtures multiply the amount of each ingredient by If. 
For 40-ounce mixtures multiply the amount of each ingredient by 2. 
For 45-ounce mixtures multiply the amount of each ingredient by 2i. 



Strength of the Food for Different Months.— First Day. 

Give no milk; put in milk sugar to mark, then fill with boiled 
water. 

Second Day. — Add 1 dipperful of top milk No. 1. 



610 THE DISEASES OF CHILDREN. 

Third Day. — Add 2 dipperfuls of top milk No, 1. 

Fourth Day. — Add 3 dipperfuls of top milk No. 1. 

Fifth to Tenth Day. — Add 4 dipperfuls of top milk No. 1. 

Tenth to Thirtieth Day. — Add 5 dipperfuls of top milk No. 1. 

One Month to Two Months. — Add 6 dipperfuls of top milk 
No. 1. 

Two Months to Four Months. — Add 7 dipperfuls of top milk 
No. 1. 

Four Months to Nine Months. — Add 10 dipperfuls of top 
milk No. 2. 

Wlien the baby needs more than 20 ounces in the 24 hours, 
fill the measuring glass twice instead of once, before putting 
the food into the baby's bottle. 

After nine months the food is prepared by shaking the quart 
bottle of milk when first obtained and using the plain mixed 
milk. 

HALE'S METHOD. 

Hale ^ suggests the following method of modifications : 
Rule 1. — To find the percentage of fat (or sugar or proteid) 
in diiry mixture multiply the number of ounces used of each 
fat (or sugar or proteid) containing factor by the percentage 
of fat (or sugar or proteid) it contains, and divide the sum of 
fat (or sugar or proteid) results by the number of ounces in the 
whole mixture. 

Example. — A mixture is made up of 

2 ounces of 10 per cent cream, 
10 ounces of whole milk, 
§ ounce of lactose, 
8 ounces of water, 

20 ounces in all, and we apply the rule. 
Fat from cream, 2 ounces multiplied by 10 per cent equals. .20 parts of fat 
Fat from milk, 10 ounces multiplied by 4 per cent equals. .40 parts of fat 

60 parts. The 
sum of fat re- 
sults. 



1 Archives of Pediatrics, May, 1908. 



APPENDIX. 611 

Sugar from cream, 2 ounces multiplied by 4.50 per cent 

equals 9 parts of sugar 

Sugar from milk, 10 ounces multiplied by 4.50 per cent 

equals 45 parts of sugar 

Sugar from lactose, 0.66 ounce multiplied by 100 per 

cent equals 66 parts of sugar 

120 parts. The 
sum of sugar re- 
sults. 

Proteids from cream, 20 ounces multiplied by 3.50 per 

cent equals 7 parts of proteids 

Proteids from milk, 10 ounces multiplied by 3.50 per 

cent equals 35 parts of proteids 

42 parts. The sum 
of proteid results. 

These sums divided by 20, the number of ounces in the mix- 
ture, will give the percentages desired, thus: 

20) 60 per cent fat, 120 per cent sugar, 42 per cent proteids. 

3 per cent fat, 6 per cent sugar, 2.1 per cent proteids. 

These percentages represent the amount of fat, sugar and 
proteids the mixture contains, and with this knowledge we can 
intelligently appreciate the strength and proportion of the in- 
gredients, and are prepared to reduce to grams, and then esti- 
mate the caloric values.^ 

This example is given to make Rule 1 more clear. The fol- 
lowing data is obtained from the mother: 

In each bottle she puts 

2 ounces of milk. 

1 ounce of cream. 

I ounce of lime water. 
21 ounces of water. 
1 heaping teaspoonful of lactose, equal to i ounce. 2 



6 ounces. 



^ An ounce equals 29.5 grams. One gram of fat yields 9.3 calories. Proteids 
and sugar each yield 4.1 calories per gram. 

^ A Chapin ounce dipper, even full of milk-sugar, varies in weight from 245 
grains to 280 grains Troy, \Yith simple moderate juggling to settle it. When sugar 



612 THE DISEASES OF CHILDREN. 

What she has told us so far means very little, and we must 
inquire further. This we do, discovering that the milk is 
skimmed milk, and that the cream is from the top 6 ounces of 
the bottle. Thus the milk used would run about .75 per cent 
fat, 4.150 per cent sugar, 3.50 per cent proteids, and the cream 
about 18 per cent fat, 4.50 per cent sugar, and 3.25 per cent 
proteids. Having learned these facts we proceed to apply 
Rule 1, first for fat, next for sugar, and last for the proteids. 

The totals then are divided by 

Milk — 2 oz. multiplied by 0.75 p. c. equals 1.50 parts of fat from the milk. 
Cream — 1 oz. multiplied by 18.00 p. c. equals 18.00 parts of fat from the cream. 

which gives us 19.50 parts of fat in all. 

Milk — 2 oz. multiplied by 4.50 p. c. equals 9.00 parts of sugar from the milk. 
Cream — 1 oz. multiplied by 4.50 p.c. equals 4.50 parts of sugar from the cream. 
Lactose — 0.20 oz. multiplied by 100.00 p.c. equals 20.00 parts of sugar from the lactose.- 



Avhich gives us 33.50 parts of sugar in all. 

Milk — 2 oz. multiplied by 3.50 p.c. equals 7.00 parts of proteids from the milk. 
Cream — 1 oz. multiplied by 3.25 p.c. equals 3.25 parts of proteids from the cream. 



which gives us 10.25 parts of proteids in all. 
The totals then are divided by 

6) Fat, 19.50 parts. Sugar, 33.50 parts. Proteids, 10.25 parts. 

3.25 p.c. fat. 5.58 p.c. sugar. 1.70 p.c. proteids. 

Rule 2. — To find the number of ounces of any factor (be it 
cream, milk, etc., or sugar) that must be used to obtain any 
desired percentage of fat (or sugar or proteids), multiply the 
number of ounces in the whole mixture by the percentage of fat 
(or sugar or proteids) desired, and divide the result by the per- 
centage in which the fat (or sugar or proteids) occurs. 

Example. — ^We wish to make up a 30 ounce mixture, contain- 
ing 2.50 per cent fat, using whole milk and water. Thirty 
ounces multiplied by 2.50 per cent equals 75 ; this divided by 
4 per cent gives 18.75 ounces as the number needed to give the 
required amount of fat. 

By way of further example, we will make up a thirty ounce 
mixture, containing 2.50 per cent of fat, 6 per cent of sugar, and 



is loosened in its can. or carton, and dipped out, a heaping tablespoonful varies from 
235 grains to 338 grains. The damper and more sticky the sugar the more will 
remain on the spoon, Mallinckrodt's and Merck's running heavier than Squibb's. 
A dipped and then struck tablespoonful runs from 140 grains to 172 grains. Here 
more of the sticky sugar pushes olif than of the dry. A dipped heaping teaspoonful 
runs from 85 to 100 grains, averaging approximately 1 to 5 ounces. A dipped and 
then struck teaspoonful holds from 39 to 47 grains. 



APPENDIX. 613 

1.75 per cent of proteids. Here the problem is complicated 
by the fact that the fat and proteids must both be entirely 
derived from the milk. The first step is, therefore, to ascertain 
the relation which the fat and proteids bear to each other. To 
do this we divide the percentage of the proteids by the per- 
centage of the fat; thus, 1.75 divided by 2.50 gives .7. Which 
means that the relation of proteids to fat is as 7 is to 10. 

We now endeavor to find what portion of a bottle of milk 
has fat and proteids in this proportion, or approximately so. 
In looking back over the percentages of fat and proteids in 
different portions of a bottle, our eyes light upon the upper 
25 ounces, which contain 5 per cent fat and 3.50 per cent 
proteids, exactly the thing we want. Having now found a 
milk with the fat and proteids in the proportions desired, we 
proceed at once to find the number of ounces necessary to give 
the required percentage of either the fat or proteids. It makes 
no difference which is chosen to work with, the proportion re- 
mains undisturbed. We will choose to work it out for the 
proteids. Applying Rule 2, we multiply 30 ounces by 1.75, 
which gives 52.50 ; this divided by 3.50 per cent gives 15 
ounces as the number of ounces needed to supply both fat and 
proteids in the desired amounts. We notice that in this case 
the amount of milk happens to be half of the bulk prepared, 
consequently the dilution is one-half, which proves our calcula- 
tion and tells us 'further that the sugar supplied by the milk is 
one-half of 4.50 per cent; that is, 2.25 per cent, making it un- 
necessary for us to work it out by Rule 1. There is, then, 2.25 
per cent of sugar supplied; 3.75 per cent must still be added 
to make up the required 6 per cent. We apply Rule 2 and 
multiply 30 ounces by 3.75 per cent, which gives 112.50, and 
this divided by 100 per cent (the percentage of sugar in lac- 
tose) gives 1.125 ounces as the amount of lactose that must be 
used. This amounts to simply finding what 3.75 per cent of 
30 ounces is, as we realize that 3.75 per cent should be written 
.0375. 

The upper third contains three times as much fat as proteids; 
that is, in the ordinary bottled milk it contains about 10 per 
cent fat and a shade less than 3.50 per cent proteids. The 



614 THE DISEASES OF CHILDREN. 

upper half contains twice as much fat as proteids; that is, 7 
per cent fat and 3.50 per cent proteids. 

In the use of 10 per cent milk it is very simple, for to obtain 
a certain percentage of fat in the 20 ounce mixture it is only 
necessary to multiply the desired percentage by 2 to find the 
amount of milk needed. This is clear when we look at it a 
little more closely. One ounce in 20 is evidently in the same 
proportion as 5 in 100; that is, 5 per cent. This 1 ounce is 
only 1/10 fat, so the amount of fat it gives is 1/10 of 5 per 
cent, which is .50 per cent, or I/2 P^^" cent; that is, one-half the 
number of ounces used. For every 1 per cent of fat desired 
2 ounces of such a milk must be used in each 20 ounce mixture. 

The proteids are one-third fat ; thus, 1 ounce of this 10 per 
cent milk yields scant .17 per cent proteids in a 20 ounce mix- 
ture. 

The sugar is a little less than half the fat, or about .23 per 
cent in the 20 ounce mixture. As lactose is 100 per cent sugar, 
each ounce added increases the sugar just 5 per cent. 

In using the upper half of the ordinary bottled milk, the 
calculations may be done as follows: This milk contains 7 
per cent fat, 4.50 per cent sugar, and 3.50 per cent proteids; 
that is, the proteids are just half the fat, and the sugar is 
.64, or approximately two-thirds of the fat, and may be so con- 
sidered. We have seen that 1 in 20 is 5 per cent. One ounce 
of milk, 7 per cent fat, in a 20 ounce mixture gives to the 
mixture that part of 5 per cent which 7 per cent is of 100 per 
cent, namely, 1/14.3; 1/14.3 of 5 per cent is .35 per cent; 
therefore, each ounce gives .35 per cent of fat, which is con- 
sidered % per cent. This enables us at a glance to tell how 
many ounces are needed to give any desired percentage, namely, 
three times as many ounces as per cent of fat wished. 

The proteids in the mixture would be in the same proportion 
as in the milk used, namely, half the fat. 

The sugar would also be in the same proportion as in the 
milk; that is, two-thirds as much as the fat. 

Example. — We wish 3 per cent fat, and take 9 ounces from 
the upper half of a bottle. Applying Rule 1 as a test, the mix- 
ture is seen to contain 3.15 per cent fat, which is close enough. 



APPENDIX. 615 

We will now, by way of a more complete example, take a 
formula and work it out. We wish in every 24 hours to give 
a baby 33 ounces of a mixture containing 2.50 per cent fat, 
7 per cent sugar, and 1.25 per cent proteids. In order to have 
a margin for waste and possible breaking of a nursing bottle, 
we will make up 40 ounces. This will require just twice what 
the 20 ounces do. To make up a 20 ounce mixture with 2.50 
per cent fat, we take as many ounces of the 7 per cent milk as 
three times the percentage of fat desired. This gives 7.50 
ounces as the number to be used. For 40 ounces twice as much 
is taken. 

The sugar is two-thirds of the fat; that is, 1.66 per cent of 
sugar is supplied by the milk. We desire 7 per cent, so there 
is lacking 5.44 per cent; that is, 5 per cent, and approximately 
1/10 of 5 per cent more. One ounce of lactose gives the 5 
per cent, and 1 drachm more is near enough to the 1/10 desired. 
Thus, 1 ounce and 1 drachm will bring the sugar up to 7 per 
cent in the 20 ounce mixture, twice as much will be needed in 
the whole amount being mixed. 

The proteids, because of their proportion, must be one-half 
the fat; that is, 1.25 per cent (or exactly 1.30 per cent), the 
percentage wished. The whole mixture will then be made as 
follows : 

15 ounces upper half of bottle. 

25 ounces water. 

2J ounces lactose. 

40 ounces 

MOFFITT'S METHOD OF CALCULATION. 

Moffitt ^ recommends the following method of calculation of 
various formula; taking average herd milk to show the fol- 
lowing analysis: fat 4 per cent, carbohydrates, 4.5 per cent, 
proteins, 3.5 per cent, and 16 per cent cream to show fat, 16 
per cent, carbohydrates 4.05 per cent, proteins, 3.2 per cent. 

Suppose a represent the per cent of fat, h the per cent of 
carbohydrates, and c the per cent of proteins in anj^ artificial 
mixture; that is, that which is commonly known as, for ex- 

^ Journal American Medical Association, vol.. Iv, no. 22. 



616 THE DISEASES OF CHILDREN. 

ample, a 3-6-1 mixture (3 per cent of fat, 6 per cent of car- 
bohydrates, and 1 per cent of proteins) we term an a-h-c mix- 
ture. Now let X represent the per cent of milk, y the per cent 
of cream, and z the per cent of milk-sugar necessary to com- 
pound such a mixture. The diluent will then be equal to 
100-(x+y). 

It is then obvious that 

4x 16y 

— -f = a or X + 4y = 25a ( 1 ) 

100 100 

4.5x 4.05y 

and + -f z = b or 90x + Sly + 2,000z = 2,000b (2) 

100 100 

3.5x 3.2y 

also -\- = c or 35x -f 32y = 1,000c. 

100 100 

By subtracting Equation 1 multiplied by 8 (8x -[- 32y i=t200a) from 
Equation 3 we have 

1,000c — 200a 

27x — 1,000c — 200a or x = 

27 
By subtracting Equation 3 from Equation 1, multiplied by 35 (35x-{- 
140y = 875a), we have 

875a— 1,000c 

108y .=1 875a — 1,000c or y = 

108 

By substituting these values of x and y in Equation 2 we have 
90 (1,000c — 200a) 81 (875a — 1,000c) 

-\- — + 2,000z 1=1 2,000b 

27 108 

that is 40,000c — 8,000a -f 7.875a — 4,000c + 24,000zr=i 24,000b 

a+ 192b — 248c 

or z = 

192 

We then have the values of x, y and z in terms of a, b and c; that is to 
say, we have the per cent of milk, cream and milk-sugar necessary to make 
up an a-b-c mixture, and any values whatever (of fat, carbohydrate and pro- 
tein percentages), such as 3, 6 and 1 may be substituted for a, b and c. 
Our formula then is 

1,000c — 200a 

per cent of milk ^ ^ ( 1 ) 

27 
875a — 1,000c 

per cent of cream i^i (2) 

108 
a+ 192b — 248c 

per cent of milk-sugar = (3) 

192 
To demonstrate the accuracy of the calculation in devising this for- 



APPENDIX. 617 

mula, suppose we desire a 4-4.5-3.5 mixture, i.e., a mixture containing 4 
per cent of proteins. It will be seen that this is cow's milk. 
Substituting 3.5 for c and 4 for a in (1), we have 



1,000x3.5 — 200x4 3,500.0 — 800 2,700 

• — — nzz: 1^1 

27 27 27 

Substituting likewise in (2), we have 

875X4—1,000X3.5 3,500 — 3,500.0 



100 







108 108 

Substituting these values in (3), and also 4.5 for b, we have 

4+192x4 5 — 248x3.5 4 + 864.0 — 868.0 

— . = = 

192 192 

showing that, m compounding a 4-4.5-3.5 mixture, we take 100 parts milk, 
no cream, no sugar and no diluent. 

Now suppose we desire a 16-4.05-3.2 mixture (cream). 
Substituting 3.2 for c and 16 for a in ( 1 ) , we have 

1,000 X 3.2 — 200 X 16 3,200.0 — 3,200 

^ = 

27 27 

Substituting likewise in ( 2 ) , we have 

875 X 16 — 1,000 X 3.2 14,000 — 3,200.0 10,800 



100 



108 108 108 

Substituting these values in ( 3 ) , and also 4.05 for b, we have 
16 + 192 X 4.05 — 248 X 3.2 16 + 777.60 — 793.6 







192 192 



showing that, in compounding a 16-4.05-3 2 mixture, we take 100 parts 
of cream, no milk, no sugar and no diluent. 

In making a table of various mixtures from this formula, 
Moffitt carries the calculations to 0.1 per cent, i, e., to three 
decimal places, which has shown results within 0.04 per cent 
of perfect accuracy in all mixtures in which he has calculated 
the percentages of fat, carbohydrates and proteins from the 
amounts of milk, cream and sugar used in compounding such 
mixtures. 

By the table from this formula 24 ounces of a 3-6-1 mixture 
require 3.5 ounces of milk, and 3.6 ounces of cream and 1.13 
ounces of milk-sugar. Now 3.5 ounces of milk and 3.6 ounces 
of cream contain 0.716 ounce of fat, i. e., 2.98 per cent of 24 
ounces (inaccurate by but 0.02 per cent) and 0.2377 ounce of 
proteins, i. e., 0.99 -j- per cent of 24 ounces (within 0.01 per cent 



618 THE DISEASES OF CHILDREN. 

of absolute accuracy), and these amounts of milk and cream 
plus the added sugar total in all 1.4333 ounces of carbohydrates 
in the 24 ounce mixture of 5.97 + per cent (within 0.03 per 
cent). 

In calculating the amounts of the ingredients in 24 ounces 
of a 3.25-6-1.25 mixture by the old formula we arrive at an 
even more inaccurate result in regard to the proteins, for C ^ 4 
ounces, M = 3.5 ounces and S = 1.14 ounces, and in 24 ounces, 
4 ouneevS of cream and 3.5 ounces of milk give 3.25 per cent 
fat (accurate) and 1.04 per cent of proteins (0.21 per cent 
out of the way), and these amounts of cream and milk with the 
added 1.14 ounces of milk-sugar give 6.08 per cent of car- 
bohydrates (0.08 per cent off) practically a 3.25-6-1 mixture 
instead of a 3.25-6-1.25. 

By this table 24 ounces of a 3.25-6-1.25 mixture require 5.328 
ounces of milk, 3.528 ounces of cream and 1.056 ounces of 
milk-sugar, giving 3.24 per cent of fat, 5.97- per cent of car- 
bohydrates and 1.24 per cent of proteins. 

The greatest inaccuracy encountered in the old formula, and 
in our table as well, is the last mixture in the table, viz., 5-7- 
3.50. By the old formula in a 24-ounce mixture we have 3 
ounces of cream, 18 ounces of milk and 0.84 ounce of milk- 
sugar. These amounts in 24 ounces give 5 per cent of fat 
(accurate), 7.38 per cent of carbohydrates (0.38 per cent off) 
and 3.02 per cent of proteins (0.48 off), practically a 5-7-3 
mixture instead of a 5-7-3.50 mixture as far as the proteins are 
concerned. 

By our table we find in 24 ounces of a 5-7-3.50 mixture we 
require of milk 22.08 ounces, cream 1.92 ounces and milk-sugar 
0.6 ounce. These amounts give of fat 4.96 per cent (0.04 off), 
carbohydrates 6.96 per cent (0.04 off') and proteins 3.47 per 
cent (but 0.03 off). 

Had the tables been carried out to one more decimal place 
all calculations would have been within 0.01 per cent of ab- 
solute accuracy. 

If barley water or other cereal water is used, as recommended 
by many to assist in breaking up the curd, it, too, may be 
added in the quantity desired before adding the water. Since 



APPENDIX. 619 

barley water contains of fat 0.05 per cent, carbohydrates 1.63 
per cent and proteins 0.09 per cent (Holt), when it alone is 
nsed as the diluent, a reduction should be made in the car- 
bohydrate per cent of the formula ; e. g., if a 3-6-1 mixture is 
desired the ingredients of a 3-5-1 mixture should be used, the 
percentage of the carbohydrates being subsequently raised by 
the addition of the barley water. The same point must be 
observed when adding the various dextrinizing powders to the 
milk mixtures. The dextrinizing process raises the sugar con- 
tent about 2 per cent, so if a 3-6-1 mixture were desired, the 
ingredients of a 3-4-1 mixture are dextrinized. 

In the modification of cow's milk by any formula it is es- 
sential to know the composition of the milk and cream used 
and while it is true that average herd milk is usually 4 per 
cent and gravity usually 16 per cent it is advisable to make the 
simple fat estimations with the Babcock centrifuge from time 
to time, for if the fat percentage is correct, the amounts of the 
other ingredients will also be correct. 

CARE OF BABIES IN HOT WEATHER. 

The following is a brochure^ issued by the Babies' Milk 
Fund Association of Louisville in 1908 on the Care of Babies 
in Hot Weather, which was distributed among the poor and 
sent to every new mother whose confinement was reported to 
the city health office: 

TO KEEP THE BABY WELL. 

1. Give it pure air day and night. 

2. Give it no food but mother's 7nill\ or milk from the bottle, 
or food directed by a physician. 

3. Whenever it cries or is fretful, do not offer it food, but 
give it ivater. 

4. Be sure that it gets enough sleep — two naps, at least, dur- 
ing the day. 

5. Do not put too much dothing on it.. 

6. Bathe it every day in a tub. 

7. Don't handle it; let it alone. 



1 Compiled by Letchworth Smith, M.D. 



620 THE DISEASES OF CHILDREN. 

THE CARE OF BABIES IN HOT WEATHER. 

Clothing. — In the hot weather a thin gauze shirt, a thin mus- 
lin slip, and a diaper. On the hottest days, the slip and diaper 
are enough. 

Keep the baby as cool and comfortable as possible. 

As soon as a diaper is soiled it should he removed. Place 
it in a pail with a cover to keep the odors in and the flies out. 
Cover it with water and wash as soon as possible in hot water, 
to which a little soda has been added. The diaper should be 
loell rinsed and thoroughly dried before being worn again. 

At least once a week all diapers should be thoroughly boiled. 

After every movement the parts soiled should be carefully 
cleansed at once. Babies often get sick from being left in soiled 
diapers. Never think of putting on any kind of baby powder 
until the skin is clean and fairly dry. 

If the skin becomes- chafed in any of the cracks or wrinkles 
apply a little zinc oxide ointment. 

Bathing. — The best time for the bath is just before a feed- 
ing — if possible, at the same time each day. 

The baby should be bathed every day in a tub. 

The water should be slightly warmer than its own body. 

Use soap that will not irritate its skin. 

Do not bathe within an hour after eating. 

In very hot weather finish the bath with a little cooler water, 
and give three or four general spongings during the day with 
cool water containing a little salt. 

If the child suffers from "prickly heat," bathe the affected 
skin with vinegar and water. But remember that a roughened 
or inflamed skin may be the sign of an infectious disease that 
needs the care of a physician. 

Sleep. — After the bath let the baby sleep for two hours. 

Such a mid-day nap should be insisted on until the child is 
a year old, and is advisable until the age of four. 

Cover the child only with a light sheet when it is hot. 

Fresh Air. — Fresh air is very necessary. 

Leave the windows wide open. Never put a child to sleep 
in a closed-up room. 

Keep it out of doors as much as possible. 



APPENDIX. 



621 



Avoid the sun on hot days. Keep on the shady side of the 
street, or in shady spots in the park, or in any shady spots 
where the air is fresh. 

Bed. — A baby's bed should be flat, firm, clean and dry. 

Feather pillows are bad things for babies to lie on, especially 
in the summer. 

Feeding. — Every mother should nurse her hahy, if she can 
possibly do so. 

No other food is so good for a baby as mother's milk. 

Of the babies that die before they get to be a year old, nine 
out of every ten are bottle fed. 

Wash the nipple with cold water before and after each 
nursing. 

The mother should eat plain, well-cooked food and should see 
to it that her bowels move at least once each day. Constipa- 
tion in the mother is bad for both mother and child. 

She should be careful as to diet and habits of life. Beer and 
tea are harmful, and in large quantities (two pints or more 
daily) may be very injurious. 

Regular Feeding. — Regularity in feeding is one of the most 
important things in the care of a baby. Irregularity in feed- 
ing leads to over-feeding in most cases, and often causes sick- 
ness, diarrhea and death. 

Feed the child at regular intervals. 

Do not nurse it every time it cries. A child is not always 
hungry when it cries, but it will eat at almost any time that 
food is offered. If it eats before its stomach is ready for a 
fresh supply of food, it may become sick. 

The baby's stomach should be given a certain length of time 
to digest the food that is put into it. It should then have a 
little rest before it is called on to digest more food. If it is not 
allowed to rest, but kept at work constantly, it will become 
exhausted, and that means that the baby will be sick. 

If a baby cries between feedings give it a drink of water that 
has been boiled and then cooled, with nothing in it. 

Even very young nursing babies should have water in hot 
weather between feedings. This can be given out of a spoon 
or a perfectly clean nursing bottle. 



622 THE DISEASES OP CHILDREN. 

Breast Feeding. — From the Third Day to the Sixth Week. 
— The baby should be nursed, every two hours during the day, 
6,. 8, 10, 12, 2, 4, 6, 8, and should be nursed only twice between 
10 p. m. and 6 a. m., not more than 10 feedings during the 24 
hours. The baby should not he alloived to nurse more than 20 
minutes at a time. Nursing longer than this may give the 
stomach more than it can properly digest before time for the 
next nursing. 

From the Sixth Week to the Third Month. — During the day 
six nursings, two and one-half hours apart, at 6, 8.30, 11, 1.30, 
4 and 6.30. From that time on till morning only two nursings 
should be allowed. 

From the Third to the Sixth Month. The nursings should 
be three hours apart during the day, at 6, 9, 12, 3, 6, 10, with 
one only betw^een that hour and 6 o'clock the next morning. 

From the Sixth to the Ninth Month.. — The times of feeding 
remain the same but the night feeding should he discontinued. 
The child may wake up in the night, but should be given a 
drink of cooled, boiled water. After a short time, if it is well, 
it will sleep through the night. 

From the Ninth to the Twelfth Month. — Nursings three and 
one-half hours apart. Five in number. None at night. 

Bottle Feeding. — If it is absolutely impossible for a mother 
to nurse her baby, it may be possible to find a wet-nurse. If 
this cannot be done, it will be necessary to put the baby on the 
milk of some animal. 

Cow's milk should not be given to young babies much under 
a year old unless it is diluted with certain amounts of clean 
water or barley water. 

The hest milk you can get is not too good for the baby. 

If you cannot afford to drink good milk yourself, you may 
be able to get along without it, but the haby needs milk and 
the cleanest milk that can be obtained. Cheap milk is not 
clean. It is usually keeping milk from getting dirty that makes 
it expensive. 

All babies should have milk that is clean enough to be cer- 
tified. 



APPENDIX. 623 

All other millv should he heated to hoiling as soon as it is 
purchased. 

To keep milk sweet get it from the milkman whose wagons, 
cans and horses look clean. If you know where he keeps his 
cows, go and see if he keeps them clean. 

Get your milk in a bucket ivith a cover so that the flies and 
dust can be kept out of it. See that the pail is ivell ivashed, 
scalded and turned upside down when not in use. 

Always keep the milk covered. Always keep it cold. 

If you cannot get ice, keep it in cold running water, or if 
this is not possible, wrap a damp cloth about the pail and set 
it in a draft of air. 

Feeding After One Year of Age. — Children should be weaned 
when 12 months old, unless the weather is very hot or a physi- 
cian orders otherwise. 

Wean gradually. — At first substitute one bottle for one nurs- 
ing. After a few da3^s give two bottles a day, and so on. 

Bottle-fed children at this age will require more than milk, 
although this should still form the chief part of their food. 

During the second year most children are badly fed. 

Four meals a day should be given, selected from the fol- 
lowing : 

Soft-boiled eggs; strained broths of beef, mutton and chicken, 
containing small pieces of stale or toasted bread; stale bread or 
toast with milk; homim^ (cooked six hours) with milk; oatmeal 
or rice (cooked three hours) with milk; cornmeal (cooked two 
hours) with milk; farina (cooked one hour) with milk. Tlie 
milk should be boiled unless it is certified milk. Do not feed 
meat, vegetables, candy, popcorn, sugar, bananas or an3^thing 
else unless told to do so by a physician. 

Summer Diarrhea. — When the baby has loose, green pas- 
sages, it means that the baby is sick and needs medical atten- 
tion. The disease is mild at first and often shows no other 
signs of illness than the diarrhea. There may be no fever. 
Such a baby often becomes dangerously ill in a short time. 

The simplest case of vomiting and diarrhea during the sum 
mer should not be neglected. 



624 THE DISEASES OF CHILDREN. 

Stop the milk at once. 

Give two teaspoonfuls of castor oil and feed nothing but 
barley water until the child can be taken to a doctor. 

Do not give it any cordials or teas or ''diarrhea mixtures." 

Flies. — Remember that flies are dirty, and often carry 
disease. 

Keep milk and other food covered or where flies cannot get 
at it. 

The fly that falls into the milk bucket may have just come 
from a privy used by a person having typhoid fever, and if 
so the one drinking the milk may contract the disease. 

Keep the soiled diapers covered so that flies cannot walk 
over them and then go to the food used in the family. 

Windows and doors should be screened, especially if there 
is a baby in the family. 

Give the Baby a Chance.— Do not get it in the habit of being 
held by its mother or by other children. 

Most babies suffer because they are used to amuse older 
people, and are forced to laugh or are tossed about and excited 
when they need to be resting quietly. 

Get it early into the habit of going to sleep without being 
rocked. It is much better for the baby to learn to go to sleep 
without this motion, and to have it do so will save much time 
for the mother and enable her to do many more important 
things in the way of keeping things clean, and of resting her- 
self. 

Children often cry when put down to sleep. If they are left 
alone and not handled or talked to they will soon go to sleep. 

Crying is one of the ways in which babies develop their 
lungs — a certain amount of it is ''natural," and will do no 
harm if you don't get nervous about it. 

Try to get people to leave the baby alone. Think how tired 
and irritable you get yourself on a hot day, and shield the baby 
as much as possible from excitement and "attention." 

"Some of these things may seem like extra work, but they 
keep the baby well, and it is far less trouble to keep a baby 
well than to take care of a sick baby." 

A Mother. 



APPENDIX. 625 

MILK MODIFICATIONS. 

Suggestive Table of Feedings. ^ 

Eemove the top 9 ounces from 1 quart of bottled milk into 
pitcher or bowl. Of this milk in the pitcher or bowl use 4 
ounces with 14: ounces of water or dextrinized gruel and two 
level tablespoonfuls of sugar. (F. 2.7, S. 6., P. .7.) 

Divide into nine feedings of 2 ounces each in separate nurs- 
ing bottles, and feed every two hours during the day and twice 
at night. 

TWO TO FOUR V^^EEKS. 

RemoA^e the top 9 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this milk in the pitcher or bowl use 7 
ounces with 20 ounces of water or dextrinized gruel and 3 level 
tablespoonfuls of sugar. (F. 3., S. 7., P. 1.) 

Divide into nine feedings of 2 to 3 ounces each in separate 
nursing bottles, and feed every two hours during the day and 
twice at night. 

SECOND MONTH. 

Remove the top 11 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this milk in the pitcher or bowl use the 
entire 11 ounces with 22 ounces of water or gruel and 4 level 
tablespoonsfuls of sugar. {F. 3., S. 7., P. 1.) 

Divide into eight feedings of 3 to 4 ounces each in separate 
nursing bottles, and feed every two and one-half hours during 
the day and once at night. 

THIRD MONTH. 

Remove the top 16 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this milk in the pitcher or bowl use 
14 ounces with 18 ounces of water or gruel and 4 level table- 
spoonfuls of sugar. (F. 3., S. 7., P. 1.4.) 

Divide into seven feedings of 4 to 5 ounces each in separate 
nursing bottles, and feed every two and one-half to three hours 
during the day and once at night. 



Chapin: Theory and Practice of Infant Feeding. 



626 THE DISEASES OF CHILDREN. 

FOUR TO SIX MONTHS. 

Remove the top 20 ounces from 1 quart of bottled milk into 
a pitcher or bowl. Of this top milk in the pitcher or bowl use 
the entire quantity with 16 ounces of water or gruel and 4 level 
tablespoonfuls of sugar. (F. 3., S. 1., P. 2.) 

Divide into six feedings of 5 to 6 ounces each in separate 
nursing bottles, and feed every three hours during the day and 
once at night. 

SEVEN TO NINE MONTHS. 

Remove the top 24 ounces from each 2 quarts of bottled milk 
into a pitcher or bowl. Of this milk in the pitcher or bowl 
use 33 ounces with 15 ounces of water or gruel and 4 level 
tablespoonfuls of sugar. (F. 3.5, S. 7., P. 2.2.) 

Divide into six feedings of 7 to 8 ounces each in separate 
nursing bottles, and feed every three hours during the day. 

TEN TO TV7ELVE MONTHS. 

Remove the top 24 ounces from each of 2 quart bottles of milk 
into a pitcher or bowl. Of this milk in the pitcher or bowl 
use 40 ounces with 8 ounces of water or gruel and 4 level table- 
spoonfuls of sugar. (F. 4., S. 7., P. 2.6.) 

Divide into five feedings of 8 to 10 ounces each in separate 
nursing bottles, and feed every three and one-half hours. 

TWELVE TO FOURTEEN MONTHS. 

Whole milk, or, if not digested well, add one-fourth gruel. 
Amount in the bottle from 9 to 12 ounces. Chicken, mutton 
or beef broths, in same amount, may also be given. 

SUGGESTIVE FORMULA (HOLT). 

First Series of Formulae. Fat to proteids, 3 : 1. 

Primary Formulas. Ten per cent milk or fat 10 per cent, 
sugar 4.3 per cent, proteids 3.3 per cent. Obtained (1) as 
upper portion of bottled milk, or (2) equal parts milk and 
(16 per cent) cream. 



APPENDIX. 



627 



DERIVED FORMULAS, GIVING QUANTITIES FOR TWENTY-OUNCE 
MIXTURES. 



II 
III 

IV 

V 

VI 



Milk sugar, 1 oz. 
Lime-water, 1 oz. 
Water qs, to 20 oz, 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 



with 2 oz. of 10% milk = 



3oz. 

4 oz. 

5 oz. 
6oz. 
7 oz. 



10% 
10% 
10% 
10% 
10% 



Fat 


Sugar 


per 


per 


cent 


cent 


1.00 


5.00 


1.50 


5.50 


2.00 


6.00 


2.50 


6.00 


3.00 


6.00 


3.50 


6.50 



Pro- 
teids 
per 
cent 



0.33 

0.50 
0.66 
0.83 
1.00 
1.16 



Second Series of Formula. Fat to proteids, 2 :1. 

Primary Formula. Seven per cent milk or fat 7 per cent, 
sugar 4.40 per cent, proteids 3.50 per cent. Obtained (1) as 
upper portion of bottled milk, or (2) by using three parts milk 
and one part (16 per cent) cream. 



DERIVED FORMULAS, GIVING QUANTITIES FOR TWENTY-OUNCE 
MIXTURES. 



I 

II 

III 

IV 

V 

VI 

VII 

VIII 

IX 



Milk sugar, 1 oz. 
Lime-water, 1 oz. 
Water qs. to 20 oz. 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 

" " 20 oz. 
-I oz. ] 



with 3 oz. of 7% milk.=; 



Milk sugar 
Lime-water 



1 oz. 



Waterqs. to20 



4 oz. 

5 oz. 
6oz. 
7 oz. 
8oz. 
9oz. 

10 oz. 

12 oz. 



7% 
1% 
7% 
7% 
7% 
7% 
7% 



1% " — 



Fat 


Sugar 


per 


per 


cent 


cent 


1.00 


5,50 


1.40' 


5.75 


1.75 


6.00 


2.10 


6.00 


2.50 


6.50 


2.80 


6.50 


3.15 


7.00 


3.50 


7.00 


4.00 


7.00 



Pro- 
teids 
per 
cent , 



0.50 

0.70 
0.87 
1.05 
1.25 
1.40 
1.55 
1.75 

2.00 



Third Series of Formulie. — Fat to proteids, 8 :7. 

Primary Formula. — Plain milk: Fat 4 per cent, sugar 4,5 
per cent, proteids 3.5 per cent. (When using Jersey or Alder- 
ney milk add one-fourth water.) 



628 THE DISEASES OF CHILDREN. 

DERIVED FORMULAS, GIVING QUANTITIES FOR TWENTY-OUNCE 
MIXTURES. 











Fat 
per 
cent 


Sugar 
per 
cent 


Pro- 
teids 
per 
cent 




r Milk sugar, 1 oz. ] 












I^ 


Lime-water, 1 oz. J- with 5 oz. plain 


milk =z 


1.00 


6.00 


0.87 




, Water qs. to 20 oz. J 












II 


. " " 20 oz. 


" 6 oz. 


" 1=1 


1.20 


6.50 


1.00 


III 


" " 20 oz. 


" 8 oz. 


" = 


1.60 


6.50 


1.40 


IV 


" " 20 oz. 


" 10 oz. " 


" = 


2.00 


7.00 


1.75 


V. 


' Milk sugar, | oz. ] 
Lime-water, 1 oz. [- 
Water qs. to 20 oz. J 


" 12 oz. 


li 


2.40 


5.00 


2:10 


VI 


20 oz. 


" 14 oz. 


a 


2.80 


5.50 


2.50 


VII 


" " 20 oz. 


" 16 oz. 


a 


3.20 


5.50 


2.80 



SUGGESTIVE FORMULiE (KERLEY). 

Kerley ^ suggests the following formulae by diluting the top 
16 ounces milk ; this will analyze, fat, 7 per cent, sugar 3.2 per 
cent, proteids 3.2 per cent. 

FROM THE THIRD TO THE TENTH DAY. 

Ounces. 
Milk (top 16 oz.) 3 Approximate Percentage Equivalent. 

Line-water ^ Fat 1.3 

Milk sugar 1 Sugar 6.6 

Eoiled water to make .... 16 Total proteid 0.6 

Ten feedings in twenty-four hours; 1 to IJ ounces at each feeding. 

FROM TENTH TO THE TWENTY-FIRST DAY. 

Milk (top 16 oz.) 6 Fat 1.75 

Lime-water li Sugar 6.8 

Milk sugar li Total proteid 0.3 

Water to make 24 

Nine to ten feedings in twenty-four hours; li ounces at each feeding. 



FROM THE THIRD TO THE SIXTH WEEK. 

Milk (top 16 oz.) 10 Fat 



2.2 



Lime-water 22i Sugar 7.0 

Milk sugar 2 Total proteid 1.0 

Water to make 32 

Eight to nine feedings in twenty-four hours; 2 to 3 ounces each feeding. 



Kerley : Treatment of Diseases of Children. 



APPENDIX. 629 

FROM THE SIXTH WEEK TO THE THIRD MONTH. 
Ounces. 

Milk (top 16 OZ.) 12 Approximate Percentage Equivalent. 

Milk sugar 2 Fat 2.6 

Lime-water 3 Sugar 7.2 

^Vater to make 32 Total proteid 1.2 

Seven to eight feedings in twenty-four hours; 2|- to 4 ounces at feeding. 

FROM THE THIRD TO THE FIFTH MONTH. 

After this age two bottles of milk are required, 16 ounces being taken 
from the top of each bottle and mixed. At this time a cereal jelly is usu- 
ally added to the food. 

Milk (top 16 oz.) 18 Fat 3.15 

Milk sugar 2 Sugar 6.4 

Lime-water 4 Total proteid 1.4 

Water to make 40 

Six feedings in twenty-four hours; 4 to 5 ounces at each feeding. 

FROM FIFTH TO THE SEVENTH MONTH. 

Milk (top 16 oz.) 21 Fat 3.50 

Milk sugar 2 Sugar 6.4 ^ 

Lime-water 5 Total proteid 1.6 

Water to make 42 

Six feedings in twenty-four hours; 5 to 7 ounces at each feeding. 

FROM THE SEVENTH TO THE NINTH MONTH. 

Milk (top 16 OZ.) 27 Fat 3.9 

Milk sugar 21 Sugar 7.0 

Lime-water 6 Total proteid 1.8 

Water to make 48 

Five to six feedings in twenty-four hours; 7 to 9 ounces at each feeding. 

FROM THE NINTH TO THE TWELFTH MONTH. 

Milk (top 16 OZ.) 35 Fat 4.3 

Milk sugar 2^ Sugar 6.5 

Lime-water 6 Total proteid 2.0 

Water to make 56 

The following are f oriimla? as used by -the Babies ' Milk Fund 
Association adapted milk laboratory: 

Per cent. Ounces. 

Fat 1 Whole milk 8 

Sugar 6 Lime-water 2 

Proteid 1 10 per cent sugar solution 11 

Water 11 



630 



THE DISEASES OP CHILDREN. 



Fat ... 
Sugar . 
Proteid 



8 BOTTLES; 4 OUNCES. 

Per cent. Ounces. 

.... 2 Top 9 ounces milk 4| 

.... 7 Bottom or skim milk 3 

.... 1 10 per cent sugar solution 17^ 

Water 3 



7 BOTTLES; 

Fat 3 

Sugar 6 

Proteid 1 



4 OUNCES EACH. 

Top 12 ounces milk 6 

Bottom or skim milk 4 

10 per cent sugar solution .... .17 
Water 8 



7 BOTTLES ; 5 OUNCES EACH. 

Fat 3.5 Top 12 ounces milk 6 

Sugar 7 Bottom or skim milk 18 

Proteid 2 10 per cent sugar solution .... 13 

Water 3 

6 BOTTLES; 7 OUNCES EACH. 

Fat 1.3 Top 16 ounces from quart 3 

Sugar 6.6 Lime-water ^ 

Proteid .• 0.6 Milk sugar 1 

Water q. s 16 



Fat ... 
Sugar . 
Proteid 



Fat ... 
Sugar . 
Proteid 



2.2 

7 
1 



2.6 

7 
1 



Fat 3.1 

Sugar 7 

Proteid 1.6 



Fat 3.93 

Sugar 7 

Proteid 1.8 



Fat 4.3 

Sugar 7.3 

Proteid 2.0 



Top 16 ounces 10 

Lime-water 2^ 

Milk sugar 2 

Water q. s 32 

Top 16 ounces 12 

Milk sugar 2 

Lime-water 3 

Water q. is 32 

Top 16 ounces from two quarts. .21 

Milk sugar 2^ 

Lime-water 5 

Water q. s. 42 

Top 16 ounces from two quarts. .27 

Lime-water 6 

Milk sugar 2^ 

Water q. s 48 

Top 16 ounces from two quarts. .35 

Milk sugar 3 

Lime-water 6 

Water q. s 56 



APPENDIX. 



631 



HESS REFRIGERATOR. 

Dr. Alfred Hess ^ of New York has suggested an inexpensive 
home-made refrigerator which, if it could be put into general 




Fig. 105. — Hess home-made refrigerator. Horizontal section. M, milk container, 
I, broken ice; C, can for holding ice; T, tin or galvanized iron cylinder to 
prevent savpdust, S, from falling into space when can is removed for pur- 
pose of emptying water. 




Fig. 106. — Hess home-made refrigerator. Vertical section. S, sawdust, excelsior 
or other cheap non-conductor of heat; T, cylinder of tin or galvanized iron; 
C, can in which is placed the milk jar, M, surrounded by broken ice, I ; news- 
papers nailed to lid of case. 

use among the poor, would prevent many cases of milk poison- 
ing among children who are fed milk teeming with bacteria, 
because it has not been kept cold. 



Journal American Medical Association, vol. li, no. 4. 



632 THE DISEASES OF CHILDREN. 

The illustrations given on page 631 show the construction of 
the box. 

METHODS AND STANDARDS FOR THE PRODUCTION 
AND DISTRIBUTION OF ^'CERTIFIED MILK."^ 

Adopted by the American Association of ]\Iedical Milk Com- 
missions, May 1, 1912. 

Certified milk is the product of dairies operated in accordance 
with accepted rules and regulations formulated by authorized 
medical milk commissions to insure its purity and adaptability 
for infants and invalids. 

The need for such a milk was experienced primarily by those 
engaged in the conservation of the life and health of infants. 
As a result there was formulated in 1892 a plan whereby cer- 
tified milk would be produced by a dairyman under the con- 
trol of a medical milk commission designated by a representa- 
tive medical society. 

The first rules designed for this purpose were those con- 
tained in an agreement entered into by a medical milk commis- 
sion and the dairyman concerned. - 

The rules contained in the original agreement mentioned rep- 
resented the essential requirements for the production of cer- 
tified milk. Following this precedent, other commissions were 
organized, which, in 1906, became federated into a national as- 
sociation known as the American Association of IMedical Milk 
Commissions. 

A fundamental object of this association was to bring about 
the uniformity of standards and their perfection. This result 
has been reached by the adoption from time to time of definite 

1 At the fifth annual meeting of the American Asscisition of Medical Milk Com- 
missions, held in Philadelphia May 25, 1911, a committee was appointed to revise 
the manual of working methods and standards for the guidance of medical milk 
commissions in the supervision of the production and distribution of certified milk. 
The committee consisted of Dr. J. W. Kerr (chairman), Dr. S. McC. Hamill, and Dr. 
Henry L. Coit. This, thpir report, was adopted at the sixth annual meeting, held at 
Louisville, Ky., May 1, 1912, as the working methods and standards of_ the associa- 
tion. The association recommends them to component commissions as ideal and to 
be as closely approximated as possible. The report includes a statement concerning 
the certified-milk movement, as well as the revised methods and standards, and is pub- 
lished for the information of those interested in the improvement of public milk sup- 
plies. 

Reprint from the Public Health Reports, vol. xxvii, no. 24, June 14, 1912. 

2 Bui. 56, Hvgienic Laboratory, Public Health and Marine Hospital Service, p. 
615. 



APPENDIX. 633 

standards relating to the veterinary inspection of herds and 
farms, the medical inspection of employees handling the milk, 
and the bacteriological and chemical examinations as to quality 
and purity. The requirements with respect to these four topics 
have been previously reported upon by committees and adopted 
by the association, and at its last annual meeting provision was 
made for their further revision and amplification. 

ORGANIZATION OF MEDICAL MILK COMMISSIONS. 

The medical milk commission is appointed by a representa- 
tive medical society, and acts under its auspices and for it, 
to encourage the production of milk of the highest possible 
standards of purity. No commission should be considered as 
certifying milk that does not conform to the standards adopted 
from time to time by the Association of Medical Milk Com- 
missions. The commission should include at least five mem- 
bers or a number sufficient to become responsible for and to 
carry on the following divisions of work: (a) The hygiene of 
the dairy, as it relates to the production and distribution of the 
milk; (6) the veterinary supervision of the herd; (c) the med- 
ical supervision of the employees; (d) the chemical and bac- 
teriological examinations of the milk. 

DUTIES OF THE COMMISSION. 

After its organization the commission should designate a 
veterinarian, a physician, a chemist, and a bacteriologist to en- 
force its methods and standards which shall be the prevailing 
methods and standards of the American Association of Med- 
ical Milk Commissions, and these officers should be required to 
render regular reports of their inspections and examinations. 
A uniform written agreement should then be entered into with 
any dairyman who is desirous of undertaking the production 
of certified milk and the investigation of whose plant shows 
it to be properly equipped for such purpose. Such agreement 
shall require the observance of the methods and standards here- 
inafter mentioned. 

Upon receipt of favorable reports from the several experts 



634 THE DISEASES OF CHILDREN. 

and committees which have made the investigations, the dairy- 
man should be authorized, in accordance with the terms of the 
agreement, to employ the term ^^ certified milk," and he shall 
be required to attach to all containers of any character used 
in distributing the milk produced under the agreement a cer- 
tificate or seal bearing the term ''certified milk," the name of 
the medical milk commission certifying it, and the day or date 
of production of the milk contained therein. 

HYGIENE OF THE DAIRY. 

UNDER THE SUPERVISION AND CONTROL OF THE VETERINARIAN 

1. Pastures or . Paddocks. — Pastures or paddocks to which 
the cows have access shall be free from marshes or stagnant 
pools, crossed by no stream which might become dangerously 
contaminated, at sufficient distances from offensive conditions 
to suffer no bad effects from them, and shall be free from plants 
which affect the milk deleteriously. 

2. Surroundings of Buildings. — The surroundings of all build- 
ings shall be kept clean and free from accumulations of dirt, 
rubbish, decayed vegetable or animal matter or animal waste, 
and the stable yard shall be well drained. 

3. Location of Buildings. — Buildings in which certified milk 
is produced and handled shall be so located as to insure proper 
shelter and good drainage, and at sufficient distance from other 
buildings, dusty roads, cultivated and dusty fields, and all other 
possible sources of contamination; provided^ in the 'case of 
unavoidable proximity to dusty roads or fields, the exposed 
side shall be screened with cheesecloth. 

4. Construction of Stables. — The stables shall be constructed 
so as to facilitate the prompt and easy removal of waste prod- 
ucts. The floors and platforms shall be made of cement or 
other nonabsorbent material, and the gutters of cement only. 
The floors shall be properly graded and drained, and the ma- 
nure gutters shall be from 6 to 8 inches deep and so placed in 
relation to the platform that all manure will drop into them. 

5. The inside surface of the walls and all interior construc- 
tion shall be smooth, with tight joints, and shall be capable of 



APPENDIX. 635 

shedding water. The ceiling shall be of smooth material and 
dust-tight. All horizontal and slanting surfaces which might 
harbor dust shall be avoided. 

6. Drinking and Feed Troughs. — Drinking troughs or basins 
shall be drained and cleaned each day, and feed troughs and 
mixing floors shall be kept in a clean and sanitary condition. 

7. Stanchions. — Stanchions when used shall be constructed 
of iron pipes or hardwood, and throat latches shall be pro- 
vided to prevent the cows from lying down between the time 
of cleaning and the time of milking. 

8. Ventilation. — The cow stables shall be provided with ade- 
quate ventilation either by means of some approved artificial 
device, or by the substitution of cheesecloth for glass in the 
windows, each cow to be provided with a minimum of 600 
cubic feet of air space. 

9. Windows. — A sufficient number of windows shall be in- 
stalled and so distributed as to provide satisfactory light and 
a maximum of sunshine ; 2 feet square of window area to each 
600 cubic feet of air space to represent the minimum. The 
coverings of such windows shall be kept free from dust and dirt. 

10. Exclusion of flies, etc. — All necessary measures should 
be taken to prevent the entrance of flies and other insects, and 
rats and other vermin into all the buildings. 

11. Exclusion of Animals from the Herd. — No horses, hogs, 
dogs, or other animals or fowls shall be allowed to come in con- 
tact with the certified herd either in the stables or elsewhere. 

12. Bedding. — No dusty or moldy hsiy or straw, bedding 
from horse stalls, or other unclean materials shall be used for 
bedding the cows. Only bedding which is clean, dry, and ab- 
sorbent may be used, preferably shavings or straw. 

13. Cleaning Stable and Disposal of Manure. — Soiled bed- 
ding and manure shall be removed at least twice daily, and the 
floors shall be swept and kept free from refuse. Such cleaning 
shall be done at least one hour before the milking time. Ma- 
nure, when removed, shall be drawn to the field or temporarily 
stored in containers so screened as to exclude flies. Manure 
shall not be even temporarily stored within 300 feet of the 
barn or dairy building. 



636 THE DISEASES OF CHILDREN. 

14. Cleaning of Cows. — Each cow in the herd shall be 
groomed daily, and no manure, mud, or filth shall be allowed to 
remain upon her during milking; for cleaning, a vacuum ap- 
paratus is recommended. 

15. Clipping". — Long hairs shall be clipped from the udder 
and flanks of the cow, and from the tail above the brush. The 
hair on the tail shall be cut so that the brush may be well above 
the ground. 

16. Cleaning of Udders. — The udders and teats of the cow 
shall be cleaned before milking; they shall be washed with a 
cloth and water, and dry wiped with another clean sterilized 
cloth — a separate cloth for drying each cow. 

17. Feeding. — ^All foodstuffs shall be kept in an apartment 
separate from and not directly communicating with the cow 
barn. They shall be brought into the barn only immediately 
before the feeding hour, which shall follow the milking. 

18. Only those foods shall be used which consist of fresh, 
palatable, or nutritious materials, such as will not injure the 
health of the cows or unfavorably affect the taste or character 
of the milk. Any dirty or moldy food or food in a state of 
decomposition or putrefaction shall not be given. 

19. A well-balanced ration shall be used, and all changes of 
food shall be made slowly. The first few feedings of grass, 
alfalfa, ensilage, green corn, or other green feeds shall be given 
in small rations and increased gradually to full ration. 

20. Exercise. — All dairy cows shall be turned out for exer- 
cise at least 2 hours in each 24 in suitable weather. Exercise 
yards shall be kept free from manure and other filth. 

21. Washing of Hands. — Conveniently located facilities shall 
be provided for the milkers to wash in before and during milk- 
ing. 

22. The hands of the milkers shall be thoroughly washed 
with soap, water, and brush and carefully dried on a clean 
towel immediately before milking. The hands of the milkers 
shall be rinsed with clean water and carefully dried before milk- 
ing each cow. The practice of moistening the hands with milk 
is forbidden. 

23. Milking Clothes. — Clean overalls, jumper, and cap shall 



APPENDIX. 637 

be worn during milking. They shall be washed or sterilized 
each day and used for no other purpose, and when not in use 
they shall be kept in a clean place, protected from dust and dirt. 

24. Thing's to be Avoided by Milkers. — While engaged about 
the dairy or in handling the milk employees shall not use 
tobacco nor intoxicating liquors. They shall keep their fingers 
away from their nose and mouth, and no milker shall permit 
his hands, fingers, lips, or tongue to come in contact with milk 
intended for sale. 

25. During milking the milkers shall be careful not to touch 
anything but the clean top of the milking stool, the milk pail, 
and the cow's teats. 

26. Milkers are forbidden to spit upon the walls or floors of 
stables, or upon the walls or floors of milk houses, or into the 
water used for cooling the milk or washing the utensils. 

27. Fore Milk. — The first streams from each teat shall be 
rejected, as this fore milk contains large numbers of bacteria. 
Such milk shall be collected into a separate vessel and not 
milked onto the floors or into the gutters. The milking shall 
be done rapidly and quietly, and the cows shall be treated 
kindly. 

28. Milk and Calving Period. — Milk from all cows shall be 
excluded for a period of 45 days before and 7 days after par- 
turition. 

29. Bloody and Stringy Milk. — If milk from any cow is 
bloody and stringy or of unnatural appearance, the milk from 
that cow shall be rejected and the cow isolated from the herd 
until the cause of such abnormal appearance has been deter- 
mined and removed, special attention being given in the mean- 
time to the feeding or to possible injuries. If dirt gets into 
the pail, the milk shall be discarded and the pail washed be- 
fore it is used. 

30. Make-up of Herd. — No cows except those receiving the 
same supervision and care as the certified herd shall be kept in 
the same barn or brought in contact with them. 

31. Employees Other than Milkers.— The requirements for 
milkers, relative to garments and cleaning of hands, shall apply 
to all other persons handling the milk, and the children unat- 



638 THE DISEASES OF CHILDREN. 

tended by adults shall not be allowed in the dairy nor in the 
stable during milking. 

32. Straining and Strainers. — Promptly after the milk is 
drawn it shall be removed from the stable to a clean room and 
then emptied from the milk pail to the can, being strained 
through strainers made of a double layer of finely meshed 
cheesecloth or absorbent cotton thoroughly sterilized. Several 
strainers shall be provided for each milking in order that they 
may be frequently changed. 

33. Dairy Building. — A dairy building shall be provided 
which shall be located at a distance from the stable and dwell- 
ing prescribed by the local commission, and there shall be no 
hogpen, privy, or manure pile at a higher level or within 300 
feet of it. 

34. The dairy building shall be kept clean and shall not be 
used for purposes other than the handling and storing of milk 
and milk utensils. It shall be provided with light and ventila- 
tion, and the floors shall be graded and water-tight. 

35. The dairy building shall be well lighted and screened and 
drained through well-trapped pipes. No animals shall be al- 
low^ed therein. No part of the dairy building shall be used for 
dwelling or lodging purposes, and the bottling room shall be 
used for no other purpose than to provide a place for clean milk 
utensils and for handling the milk. During bottling this room 
shall be entered only by persons employed therein. The bot- 
tling room shall be kept scrupulously clean and free from odors. 

36. Temperature of Milk. — ^Proper cooling to reduce the tem- 
perature to 45° F. shall be used, and aerators shall be so situ- 
ated that they can be protected from flies, dust, and odors. The 
milk shall be cooled immediately after being milked, and main- 
tained at a temperature between 35° and 45° F. until delivered 
to the customer. 

37. Sealing of Bottles. — Milk, after being cooled and bottled, 
shall be immediately sealed in a manner satisfactory to- the com- 
mission, but such seal shall include a sterile hood which com- 
pletely covers the lip of the bottle. 

38. Cleaning and Sterilizing of Bottles. — The dairy building 
shall be provided with approved apparatus for the cleansing and 



APPENDIX. 639 

sterilizing of all bottles and utensils used in milk production. 
All bottles and utensils shall be- thoroughly cleaned by hot water 
and sal soda, or equally pure agent, rinsed until the cleaning 
water is thoroughly removed, then exposed to live steam or boil- 
ing water at least 20 minutes, and then kept inverted until used, 
in a place free from dust and other contaminating materials. 

39. Utensils. — All utensils shall be so constructed as to be 
easily cleaned. The milk pail should preferably have an ellip- 
tical opening 5 by 7 inches in diameter. The cover of this pail 
should be so convex as to make the entire interior of the pail 
visible and accessible for cleaning. The pail shall be made of 
heavy seamless tin, and with seams which are flushed and made 
smooth by solder. Wooden pails, galvanized-iron pails, or pails 
made of rough, porous materials, are forbidden. All utensils 
used in milking shall be kept in good repair. 

40. Water Supply. — The entire water supply shall be abso- 
lutely free from contamination, and shall be sufficient for all 
dairy purposes. It shall be protected against flood or surface 
drainage, and shall be conveniently situated in relation to the 
milk house. 

41. Privies, etc., in Relation to Water Supply. — Privies, pig- 
pens, manure piles, and all other possible sources of contamina- 
tion shall be so situated on the farm as to render impossible the 
contamination of the water supply, and shall be so protected by 
use of screens and other measures as to prevent their becoming 
breeding grounds for flies. 

42. Toilet Rooms. — Toilet facilities for the milkers shall be 
provided and located outside of the stable or milk house. These 
toilets shall be properly screened, shall be kept clean, and shall 
be accessible to wash basins, water, nail brush, soap and towels, 
and the milkers shall be required to wash and dry their hands 
immediately after leaving the toilet room. 

Transportation. 

43. In transit the milk packages shall be kept free from dust 
and dirt. The wagon, trays, and crates shall be kept scrupu- 
lously clean. No bottles shall be collected from houses in which 
communicable diseases prevail, unless a separate wagon is used 



640 THE DISEASES OF CHILDREN. 

and under conditions prescribed by the department of health 
and the medical milk commission. 

44. All certified milk shall reach the consumer within 30 hours 
after milking. 

Veterinary Supervision of the Herd. 

45. Tuberculin Test. — The herd shall be free from tuber- 
culosis, as shown by the proper application of the tuberculin test, 
The test shall be applied in accordance with the rules and regu- 
lations of the United States Government, and all reactors shall 
be removed immediately from the farm.^ 

46. Xo new animals shall be admitted to the herd without first 
having passed a satisfactory tuberculin test, made in accordance 
with the rules and regulations mentioned ; the tuberculin to be 
obtained and applied only by the official veterinarian of the 
commission. 

47. Immediately following the application of the tuberculin 
test to a herd for the purpose of eliminating tuberculous cattle, 
the cow stable and exercising yards shall be disinfected by the 
veterinary inspector in accordance with the rules and regula- 
tions of the United States Government.^ 

48. A second tuberculin test shall follow each primary test 
after an interval of six months, and shall be applied in accord- 
ance with the rules and regulations mentioned. Thereafter,^ 
tuberculin tests shall be reapplied annually, but it is recom- 
mended that the retests be applied semiannually. 

49. Identification of Cows. — Each dairy cow in each of the 
certified herds shall be labeled or tagged with a number or mark 
which will permanently identify her. 

50. Herd-book Record. — Each cow in the herd shall be reg- 
istered in a herd book, which register shall be accurately kept 
so that her entrance and departure from the herd and her tuber- 
culin testing can be identified. 

51. A copy of this herd-book record shall be kept in the hands 
of the veterinarian of the medical milk commission under which 
the dairy farm is operating, and the veterinarian shall be made 
responsible for the accuracy of this record. 



1 See Circular of Instructions issued by the Bureau of Animal Industry for mak- 
ing tuberculin tests and for the disinfection of premises. 



APPENDIX. 641 

52. Dates of Tuberculin Tests. — The dates of the annual 
tuberculin tests shall be definitely arranged by the medical milk 
commission, and all of the results of such tests shall be recorded, 
by the veterinarian and regularly reported to the secretary of 
the medical milk commission issuing the certificate. 

53. The results of all tuberculin tests shall be kept on file by 
each medical milk commission, and a copy of all such tests shall 
be made available to the American Association of Medical Milk 
Commissions for statistical purposes. 

54. The proper designated officers of the American Associa- 
tion of Medical Milk Commissions should receive copies of reports 
of all of the annual, semiannual, and other official tuberculin 
tests which are made and keep copies of the same on file and 
compile them annually for the use of the association. 

55. Disposition of Cows Sick with Diseases other than Tuber- 
culosis. — Cows having rheumatism, leukorrhea, inflammation 
of the uterus, severe diarrhea, or diseases of the udder, or cows 
that from any other cause may be a menace to the herd shall be 
removed from the herd, placed in a building separate from that 
which may be used for the isolation of cows with tuberculosis, 
unless such building has been properly disinfected since it was 
last used for this purpose. The milk from such cows shall not 
be used, nor shall the cows be restored to the herd until permis- 
sion has been given by the veterinary inspector after a careful 
physical examination. 

56. Notification of Veterinary Inspector. — In the event of 
the occurrence of any of the diseases just described between the 
visits of the veterinary inspector, or if at any time a number 
of cows become sick at one time in such a way as to suggest the 
outbreak of a contagious disease or poisoning, it shall be the dutj^ 
of the dairyman to withdraw such sickened cattle from the herd, 
to destroy their milk, and to notify the veterinary inspector by 
telegraph or telephone immediately. 

57. Emaciated Cows. — Cows that are emaciated from chronic 
diseases or from any cause that in the opinion of the veterinary 
inspector may endanger the quality of the milk, shall be re- 
moved from the herd. 



642 ■ THE DISEASES OF CHILDREN. 

Bacteriological Standards. 

58. Bacterial Counts. — Certified milk shall contain less than 
10,000 bacteria per cubic centimeter when delivered. In case a 
count exceeding 10,000 bacteria per cubic centimeter is found, 
daily counts shall be made, and if normal counts are not restored 
within 10 days the certificate shall be suspended. 

59. Bacterial counts shall be made at least once a week. 

60. Collection of Samples. — The samples to be examined 
shall be obtained from milk as offered for sale and shall be taken 
by a representative of the milk commission. The samples shall 
be received in the original packages, in properly iced contain- 
ers, and they shall be so kept until examined, so as to limit as 
far as possible changes in their bacterial content. 

61. For the purpose of ascertaining the temperature, a sepa- 
rate original package shall be used, and the temperature taken 
at the time of collecting the sample, using for the purpose a 
standardized thermometer graduated in the centigrade scale. 

. 62. Interval Between Milking and Plating. — The examina- 
tions shall be made as soon after collection of the samples as 
possible, and in no case shall the interval between milking and 
plating the samples be longer than 40 hours. 

63. Plating. — The packages shall be opened with aseptic 
precautions after the milk has been thoroughly mixed by vig- 
orously reversing and shaking the container 25 times. 

64. Two plates at least shall be made for each sample of milk, 
and there shall also be made a control of each lot of medium 
and apparatus used at each testing. The plates shall be grown 
at 37° C. for 48 hours. 

65. In making the plates there shall be used agaragar media 
containing 1.5 per cent agar and giving a reaction of 1.0 to 
phenolphthalein. 

The following is the method recommended by a committee of the Amer- 
ican Public Health Association for the making of the media, modified, how- 
ever, as to the agar content and reaction to conform to the requirements 
specified in section 65 : 

1. Boil 15 grams of thread agar in 500 cc. of water for half an hour and 
make up weight to 500 g. or digest for 10 minutes in the autoclave at 110° 
C. Let this cool to about 60° C. 



APPENDIX. 643 

2. Infuse 500 g. finely chopped lean beef for 24 hours with its own weight 
of distilled water in the refrigerator. 

3. Make up any loss by evaporation. 

4. Strain infusion through cotton flannel, using pressure. 

5. Weigh filtered infusion. 

6. Add Witte's peptone, 2 per cent. 

7. Warm on water bath, stirring until peptone is dissolved and not al- 
lowing temperature to rise above 60° C. 

8. To the 500 grams of meat infusion (with peptone) add 500 g. of the 
2 per cent agar, keeping the temperature below 60° C. 

9. Heat over boiling water (or steam) bath 30 minutes. 

10. Restore weight lost by evaporation. 

11. Titrate after boiling one minute to expel carbolic acid. 

12. Adjust reaction to final point desired -|- 1 by adding normal sodium 
hydrate. 

13. Boil two minutes over free flame, constantly stirring. 

14. Restore weight lost by evaporation'. 

15. Filt-er through absorbent^ cotton or coarse filter paper, passing the 
filtrate through the filter repeatedly until clear. 

16. Titrate and record the final reaction. 

17. Tube (10 cc. to a tube) and sterilize in autoclave one hour at 15 
pounds pressure or in the streaming steam for 20 minutes on three succes- 
sive days. 

66. Samples of milk for plating shall be diluted in the pro- 
portion of 1 part of milk to 99 parts of sterile water; shake 25 
times and plate 1 cc. of the dilution. 

The committee on bacterial milk analyses of the American Public Health 
Association in Part IV of its report presented details with respect to plat- 
ing apparatus and technique in part as follows: 

Plating apparatus. — For plating it is best to have a water bath in which 
to melt the media and a water-jacketed water bath for keeping it at the re- 
quired temperature; a wire rack which should fit both the water baths for 
holding the media tubes; a thermometer for recording the temperature of 
the water in the water- jacketed bath, sterile 1 cc. pipettes, sterile Petri 
dishes, and sterile dilution water in measured quantities. 

Dilutions. — Ordinary potable water, sterilized, may be used for dilutions. 
Occasionally spore forms are found in such water which resist ordinary 
autoclave sterilization; in such cases distilled water may be used or the 
autoclave pressure increased. With dilution water in 8-ounce bottles cali- 
brated for 99 cubic centimeters ... all the necessary dilutions may be 
made. 

Short, wide-mouthed "blakes" or wide-mouthed French square bottles are 
more easily handled and more economical of space than other forms of 
bottles or flasks. 



644 THE DISEASES OF CHILDREN. 

Eight-ounce bottles are the best, as the required amount of dilution water 
only about half fills them, leaving room for shaking. Long-fiber nonab- 
sorbent cotton should be used for plugs. It is well to use care in selecting 
cotton for this purpose to avoid short-fiber or dusty cotton, which give a 
cloud of lint-like particles on shaking. Bottles . . . should be filled a little 
over the 99 cc. . . . to allow for loss during sterilization. 

Pipettes. — Straight sides 1 cc. pipettes are more easily handled than 
those with bulbs; they may be made from ordinary three-sixteenths inch 
glass tubing and should be about 10 inches in length. 

Plating technique. — The agar after melting should be kept in the water- 
jacketed water bath between 40° C. and 45° C. for at least 15 minutes be- 
fore using to make sure that the agar itself has reached the temperature of 
the surrounding water. If used too warm, the heat may destroy some of 
the bacteria or retard their growth. 

Shake the milk sample 25 times, then with a sterile pipette transfer 1 cc. 
to the first dilution water and rinse the pipette by drawing dilution water 
to the mark and expelling; this gives a dilution of 1 to 100. 

. . . Then with a sterile pipette transfer 1 cc. to the Petri dish, using 
care to raise the cover only as far as necessary to insert the end of the 
pipette. 

Take the tube of agar from the water bath, wipe the water from outside 
the tube with a piece of cloth, remove the plug, pass the mouth of the tube 
through a flame, and pour the agar into the plate, using the same care as 
before to avoid exposure of the plate contents to the air. 

Carefully and thoroughly mix the agar and diluted milk in the Petri dish 
by a rotary motion, avoiding the formation of air bubbles or slopping the 
agar, and after allowing the agar to harden for at least 15 minutes at 
room temperature, place the dish bottom down in the incubator. 

Plating should always be done in a place free from dust or currents of 
air. 

In order that colonies may have sufficient food for proper development 
10 cc. of agar shall be used for each plate. 

67. Determination of Taste and Odor of Milk. — After the 
plates have been prepared and placed in the incubator, the taste 
and odor of the milk shall be determined after warming the milk 
to 100° F.i 

68. Counts. — The total number of colonies on each plate 
should be counted, and the results expressed in multiples of the 
dilution factor. Colonies too small to be seen with the naked 
eye or with slight magnification shall not be considered in the 
count. 



1 Should it be deemed desirable and necessary to conduct tests for sediment, the 
presence of special bacteria, or the number of leucocytes, the methods adopted by the 
committee of the American Public Health Association should be followed. 



APPENDIX. 645 

69. Records of Bacteriologic Tests. — The results of all bac- 
terial tests shall be kept on file by the secretary of each com- 
mission, copies of which should be made available annually for 
the use of the American Association of Medical Milk Commissions. 

Chemical Standards and Methods. 

The methods that must be followed in carrying out the chem- 
ical investigations essential to the protection of certified milk are 
so complicated that in order to keep the fees of the chemist at 
a reasonable figure, there must be eliminated from the examina- 
tion those procedures which, whilst they might be helpful and 
interesting, are in no sense necessary. 

For this reason the determination of the water, the total solids 
and the milk sugar is not required as a part of the routine ex- 
amination. 

70. The chemical anaylses shall be made by a competent chem- 
ist designated by the medical milk commission. 

71. Method of Obtaining Samples. — The samples to be ex- 
amined by the chemist shall have been examined previously by 
the bacteriologist designated by the medical milk commission, as 
to temperature, odor, taste, and bacterial content. 

72. Fat Standards. — The fat standard for certified milk shall 
be 4 per cent, with a permissible range of variation of from 
3.5 to 4.5 per cent. 

73. The fat standard for certified cream shall be not less than 
18 per cent. 

74. If it is desired to sell higher fat-percentage milks or 
creams as certified milks or creams, the range of variation for 
such milks shall be 0.5 per cent on either side of the advertised 
percentage and the range of variations for such creams shall be 
2 per cent on either side of the advertised percentage. 

75. The fat content of certified milks and creams shall be de- 
termined at least once each month. 

76. The methods recommended for this purpose are the Bab- 
cock (a), the Leffmann-Beam (&), and the Gerber (c). 

(a) BahcocJc test. — The Babcock test is based on the fact that strong 
sulphuric acid will dissolve the nonfatty solid constituents of milk, and 
thus enable the fat to separate on standing. It can be conducted by any 
of the Babcock outfits which are purchasable in the market. 



646 THE DISEASES OF CHILDREN. 

"The test is made by placing in the special test bottle 8 grams (17.0 
cc.) of milk. To this is added, from a pipette, burette, or measuring bottle, 
17.5 cc. commercial sulphuric acid of a specific gravity of 1.82 to 1.83. 
The contents of the bottle are carefully and thoroughly mixed by a rotary 
motion. The mixture becomes brown and heat is generated. The test 
bottle is now placed in a properly balanced centrifuge and whirled for 5 
minutes at a speed of from 800 to 1,200 revolutions per minute. Hot 
water is then added to fill the bottle to the lower part of the neck, after 
which it is again whirled for two minutes. Now, enough hot water is 
added to fioat the column of fat into the graduated portion of the neck 
of the bottle, and the whirling is repeated for a minute. The amount of 
fat is read while the neck of the bottle is still hot. The reading is from 
the upper limits of the meniscus. A pair of calipers is of assistance in 
measuring the column of fat." (Jensen's Milk Hygiene, Leonard Pear- 
son's translation.) 

(6) Leffmann-Beam test. — The distinctive feature is the use of fusel oil, 
the effect of which is to produce a greater difference in surface tension be- 
tween the fat and the liquid in which it is suspended, and thus promote its 
readier separation. This effect has been found to be heightened by the 
presence of a small amount of hydrochloric acid. 

The test bottles have a capacity of about 30 cc. and are provided with a 
graduated neck, each division of which represents 9.1 per cent by weight 
of butter fat. 

Fifteen centimeters of the milk are measured into the bottle, 3 cc. of 
a mixture of equal parts of amyl alcohol and strong hydrochloric acid added 
and mixed. Then 9 cc. of concentrated sulphuric acid is added in por- 
tions of about 1 cc; after each addition the liquids are mixed by giving 
the bottle a gyratory motion. If the fluiH has not lost all of its milky 
color by this treatment, a little more concentrated acid must be added. 
The neck of the bottle is now immediately filled at about the zero point 
with one part sulphuric acid and two parts water, well mixed just before 
using. Both the liquid in the bottle and the diluted acid must be hot. 
The bottle is then placed at once m the centrifugal machine; after rota- 
tion from One to two minutes, the fat will collect in the neck of the bottle 
and the percentage may be read off. 

(c) Gerher's test. — This test is applied as follows: The test bottles are 
put into the stand with the mouths uppermost; then, with the pipette 
designed for the purpose, or with an automatic measurer, 10 cc. of sul- 
phuric acid are filled into the test bottle, care being taken not to allow 
any to come in contact with the neck. The few drops remaining in the 
tip of the pipette should not be blown out. Then 11 cc. of milk are 
measured with the proper pipette and allowed to flow slowly onto the 
acid, so that the two liquids mix as little as possible. Finally, the amyl 
alcohol is added. (It is important to use the reagents in the proper order, 
which is — sulphuric acid, milk, amyl alcohol. If the sulphuric acid is fol- 
lowed by amyl alcohol and the milk last, then the result is sometimes in- 



APPENDIX. 647 

correct.) A rubber stopper, which must not be damaged, is then fitted into 
the mouth of the test bottle, and the contents are well shaken, the thumb 
being kept on the stopper to prevent it coming out. As a considerable 
amount of heat is generated by the action of the sulphuric acid on the 
milk, the test bottle should be wrapped in a cloth. 

The shaking of the sample must be done thoroughly and quickly, and 
the test bottle inverted several times, so that the liquid in the neck be- 
comes thoroughly mixed. By pressing in the rubber stopper the height 
of the liquid can be brought to about the zero point on the scale. 

If only a few samples have to be analyzed and the room is warm, the 
test bottles can be put into the centrifuge without any preliminary heat- 
ing, otherwise the test bottles must be warmed for a few minutes (not 
longer) in the water bath at a temperature of 60° to 65° C. When the 
temperature rises higher than this, say above 70° C, the rubber stopper is 
liable to be blown out of the test bottle. After the test bottles have been 
heated they are arranged symmetrically in the centrifuge and whirled for 
3 to 4 minutes at a speed of about 1,000 revolutions per minute. When 
the centrifuge has a heating arrangement attached to it, the preliminary 
warming is not, of course, necessary. When the test bottles are taken out 
of the centrifuge, they are again placed in the water bath at a tempera- 
ture of 60° to 65° C, and left there for several minutes before being read; 
where the centrifuge is heated, the tubes can be read off as taken from 
the centrifuge. 

By carefully screwing in the rubber stopper, or even by pressing it, the 
loAver limit of the fat column is brought onto one of the main divisions of 
the scale, and then, by holding the test bottle against the light the height 
of the column of fat can be accurately ascertained. The lowest point of 
the meniscus is taken as the level when reading the upper surface of the 
fat in a sample of whole milk, and the middle of the meniscus for separated 
milk. 

If the column of fat is not clear and sharply defined, the sample must 
be again whirled in the centrifuge. 

Each division on the scale is equivalent to 0.1 per cent, so it is very 
easy to read to 0.05 per cent*, or, with a lens, to 0.025 per cent. If the 
number which is read off is multiplied by 0.1, then the percentage quantity 
of fat in the milk is obtained; e. g., if the number on the scale was 36.5, 
then the percentage of fat is 3.65. (Milk and Dairj' Products, Barthel; 
translated by Goodwin, p. 71.) 

77. Before condemning samples of milk which have fallen out- 
side the limits allowed, the chemist shall have determined, by 
control ether extractions, that his apparatus and his technique 
are reliable. 

78. Protein Standard. — The protein standard for certified 



648 THE DISEASES OF CHILDREN. 

milk shall be 3.50 per cent with a permissible range of variation 
of from 3 to 4 per cent. 

79. The protein standard for certified cream shall correspond 
to the protein standard for certified milk. 

80. The protein content shall be determined only when any 
special consideration seems to the medical milk commission to 
make it desirable. 

81. It shall be determined by the Kjeldahl method, using the 
Gunning or some other reliable modification, and employing the 
factor 6.25 in reckoning the protein from the nitrogen. 

Kjeldahl method. — Five cubic centimeters of milk are measured carefully 
into a flat-bottom 800 cc. Jena flask, 20 cc. of concentrated sulphuric acid 
(C. P.; sp. gr., 1.84) are added, and 0.7 gram of mercuric oxid (or its 
equivalent in metallic mercury) ; the mixture is then heated over direct 
flame until it is straw-colored or perfectly white ; a few crystals of potas- 
sium permanganate are now added till the color of the liquid remains 
green. All the nitrogen in the milk has then been converted into the 
form of ammonium sulphate. After cooling, 200 cc. of ammonia-free dis- 
tilled water are added, 20 cc. of a solution of potassium sulphide (con- 
taining 40 grams sulphide per liter), and a fraction of a gram of powdered 
zinc. A quantity of semi-normal HCl solution more than sufRcient to 
neutralize the ammonia obtained in the oxidation of the milk is now care- 
fully measured out from a delicate burette (divided into ^q ^c.) into an 
Erlenmeyer flask and the flask connected with a distillation apparatus. At 
the other end the Jena flask containing the watery solution of the am- 
monium sulphate is connected, after adding 50 cc. of a concentrated soda 
solution ( 1 pound "pure potash" dissolved in 500 cc. of distilled water and 
allowed to settle) ; the contents of the Jena flask are now heated to boil- 
ing, and the distillation is continued for 40 minutes to an hour, until all 
ammonia has been distilled over. 

The excess of acid in the Erlenmeyer receiving flask is then accurately 
titrated back by means of a tenth-normal standard ammonia solution, using 
a cochineal solution as an indicator. From the amount of acid used the 
per cent of nitrogen is obtained; and from it the per cent of casein and 
albumen in the milk by multiplying by 6.25. The amount of nitrogen con- 
tained in the chemicals used is determined by blank experiments and de- 
ducted from the nitrogen obtained as described, (Farrington and Woll, 
Testing Milk and Its Products, p. 221.) 

82. Coloring Matter and Preservatives. — All certified milks 
and creams shall be free from adulteration, and coloring mat- 
ter and preservatives shall not be added thereto. 



APPENDIX. 649 

83. Tests for the detection of added coloring matter shall be 
applied whenever the color of the milk or cream is such as to 
arouse suspicion. 

Test for coloring matter. — The presence of foreign coloring matter in 
milk is easily shown by shaking 10 cc. of the milk with an ec^^iial quantity 
of ether; on standing, a clear ether solution will rise to the surface; if 
artificial coloring matter has been added to the milk, the solution will be 
yellow colored, the intensity of the color indicating the quantity added; 
natural fresh milk will give a colorless ether solution. (Testing Milk and 
its Products, Farrington and ^Yoll, p. 244.) 

S4t. Tests for the detection of formaldehyde, borax, and 
boracic acid shall be applied at least once each month. Occa- 
sionally application of tests for the detection of salicylic acid, 
benzoic acid, and the benzoates are also recommended. 

Test for the detection of formaldehyde. — Five cubic centimeters of milk 
is measured into a white porcelain dish, and a similar quantity of water 
added; 10 cc. of HCl, containing a trace of Fe^Cle is added, and the mix- 
ture is heated very slowly. If formaldehyde is present, a violet color will 
be formed. (Testing Milk and Its Products, Farrington and Woll, p. 249.) 

Test for horacic acid {horax, lorates, preservaline, etc.). — One hundred 
cubic centimeters of milk are made alkaline with a soda or potasJi solu- 
tion, aud then evaporated to dryness and incinerated. The ash is dissolved 
in water, to which a little hydrochloric acid has been added, and the solu- 
tion filtered. A strip of turmeric paper moistened with the filtrate will 
be colored reddish brown when dried at 100° C. on a watch glass, if boracic 
acid is present. 

If a little alcohol is poured over the ash to which concentrated sulphuric 
acid has been added, and fire is set to the alcohol, after a little this will 
burn with a yellowish-green tint, especially noticeable if the ash is stirred 
with a glass rod and when the flame is about to go out. — (Testing Milk 
and Its Products, Farrington and Woll, p. 247.) 

Test for salicylic acid {salicylates, etc.) — Twenty cubic centimeters of 
milk are acidulated with sulphuric acid and shaken with ether: the ether 
solution is evaporated, and the residue treated with alcohol and a little 
iron-chlorid solution; a deep violet color will be obtained in the presence 
of salicylic acid. — (Testing Milk and Its Products, Farrington and Woll, 
p. 248.) 

Test for henzoic acid. — Two hundred and fifty to five hundred cubic cen- 
timeters of milk are made alkaline with a few drops of lime or baryta 
water, and then evaporated to about a quarter of the milk. Powdered gyp- 
sum is stirred into the remaining liquid until a paste is formed, which 
is then dried on the water bath. The gypsum only serves to hasten the 



650 THE DISEASES OF CHILDREN. 

drying, and powdered pumice stone or sand can be used equally well. When 
the mass is dry, it is finely powdered and moistened with dilute sulphuric 
acid and shaken out three or four times with about twice the volume of 50 
per cent alcohol, in which benzoic acid is easily soluble in the cold, the 
fat only being dissolved to a very slight extent or not at all. The acid al- 
coholic liquid from the various extractions, which contains milk sugar 
and inorganic salts in addition to the benzoic acid, is neutralized with 
baryta water and evaporated to a small bulk. Dilute sulphuric acid is 
again added, and the liquid shaken out with small quantities of ether. 
On evaporation of the ether, the benzoic acid is left behind in almost pure 
state, the only impurities being small quantities of fat or ash. 

The benzoic acid which is obtained is dissolved in a small quantity of 
warm water, a drop of sodium acetate and neutral ferric chloride added, 
and the red precipitate of benzoate of iron indicates the presence of the 
acid. (Milk and Dairy Products, Barthel, translated by Goodwin, p. 121.) 

85. Detection of Heated Milk. — Certified milk or cream shall 
not be subjected to heat unless specially directed by the com- 
mission to meet emergencies. 

86. Tests to determine whether such milks and creams have 
been subjected to heat shall be applied at least once each month. 

Detection of heated milk — Storch's metJiod. — Five cubic centimeters of 
milk are poured into a test tube; a drop of weak solution of hydrogen 
dioxide (about 0,2 per cent) which contains about 0.1 per cent sulphuric 
acid, is added, and two drops of a 2 per cent solution of paraphenylendiamin 
(solution should be renewed quite often), then the fluid is shaken. If the 
milk or the cream becomes, at once, indigo blue, or the whey violet or red- 
dish brown, then this has not been heated or, at all events, it has not 
been heated higher than 78° C. (172.5° F.) ; if the milk becomes a light 
bluish gray immediately or in the course of half a minute, then it has been 
heated to 79° to 80° C. (174.2° to 176° F.). If the color remains white, 
the milk has been heated at least to 80° C. (176° F.). In the examination 
of sour milk or sour buttermilk, lime water must be added, as the color 
reaction is not shown in acid solution. 

Arnold's guaiac method. — A little milk is poured into a test tube and u, 
little tincture of guaiac is added, drop by drop. If the milk has not been 
heated to 80° C. (176° F. ) a blue zone is formed between the two fluids: 
heated milk gives no reaction, but remains white. The guaiac tincture 
should not be used perfectly fresh, but should have stood a few days and' 
its potency have been determined. Thereafter it can be used indefinitely. 
These tests for heated milk are only active in the case of milks which 
have been heated to 176° F. or 80° C. (Jensen's Milk Hygiene, Pearson's 
translation, p. 192.) 

Microscopic test for heated {pasteurized) milk — Frost and Ravenel. — 



APPENDIX. 651 

About 15 cc. of milk are centrifuged for five minutes, or long enough to 
throw down the leucocytes. The cream layer is then completely removed 
with absorbent cotton and the milk drawn off with a pipette, or a fine- 
pointed tube attached to a Chapman air pump. Only about 2 mm. of milk 
are left above the sediment which is in the bottom of the sedimentation 
tube. 

The stain, which is an aqueous solution of safranin 0, soluble in water, 
is then added very slowly from an opsonizing pipette. The important thing 
is to mix stain and milk so slowly that clotting does not take place. The 
stain is added until a deep opaque rose color is obtained. After standing 
three minutes, by means of the opsonizing pipette, which has been washed 
out in hot water, the stained sediment is then transferred to slides. A 
small drop is placed at the end of each of several slides and spread by 
means of a glass spreader, as in Wright's method for opsonic index de- 
terminations. 

In an unheated milk the polymorphonuclear leucocytes have their pro- 
toplasm slightly tinged or are unstained. 

In heated milk the polymorphonuclear leucocytes have their nuclei 
stained. In milk heated to 63° C. or above, practically all of the leucocytes 
have their nuclei definitely stained. When milk is heated at a lower tem- 
perature the nuclei are not all stained above 60° C. The majority, how- 
ever, are stained. 

87. Specific Gravity. — The specific gravity of certified milk 
shall range from 1.029 to 1.034. 

88. The specific gravity shall be determined at least once each 
month. 

The Quevenne lactodensimeter is recommended for the determination of 
the specific gravity. It is made like an ordinary aerometer and divided 
into degrees which correspond to a specific gravity from 1.014 to 1.040, or 
only from 1.022 to 1.038, since, by the latter division, a greater space is 
gained between the different degrees without unduly lengthening the in- 
strument. From such a lactodensimeter one can easily read off four deci- 
mal places. 

The milk the specific gravity of which is to be determined is well shaken 
and poured into a high glass cylinder of suitable diameter; the aerometer 
is dropped in slowly, in order to prevent its bobbing up and down, (The 
bulb should be free from adhering air bubbles.) The figures on the stem 
are the second and third decimals of the numbers of the specific gravity, so 
that 34 is to be read 1.034. For this examination, the temperature of the 
milk must be 15° C. (60° F.) ; if it is not, the specific gravity of the milk 
at 15° C. must be calculated from the specific gravity found and from the 
temperature, for in milk inspection and analysis this is the standard. 



652 THE DISEASES OF CHILDREN. 

Methods and Regulations for the Medical Examination of Em- 
ployees, their Health and Personal Hygiene. 

89. A medical officer, known as the attending dairy physician, 
shall be selected by the commission who should reside near the 
dairy producing certified milk. He shall be a physician in good 
standing and authorized by law to practice medicine ; he shall 
be responsible to the commission and subject to its direction. 
In case more than one dairy is under the control of the com- 
mission and they are in different localities, a separate physician 
should be designated for employment for the supervision of 
each dairy. 

90. Before any person shall come on the premises to live and 
remain as an employee, such person, before being engaged in 
milking or the handling of milk, shall be subjected to a com- 
plete physical examination by the attending physician. No per- 
son shall be employed who has not been vaccinated recently or 
who upon examination is found to have a sore throat, or to be 
suffering from any form of tuberculosis, venereal disease, con- 
junctivitis, diarrhea, dysentery, or who has recently had typhoid 
fever or is proved to be a typhoid carrier, or who has any in- 
flammatory disease of the respiratory tract, or any suppurative 
process or infectious skin eruption, or any disease of an infec- 
tious or contagious nature, or who has recently been associated 
with children sick with contagious disease. 

91. In addition to ordinary habits of personal cleanliness all 
milkers shall have well-trimmed hair, wear close-fitting caps, 
and have clean-shaven faces. 

92. When the milkers live upon the premises their dormitories 
shall be constructed and operated according to plans approved 
by the commission. A separate bed shall be provided for each 
milker and each bed shall be kept supplied with clean bedclothes. 
Proper bathing facilities shall be provided for all employees on 
the dairy premises, preferably a shower bath, and frequent bath- 
ing shall be enjoined. 

93. In case the employees live on the dairy premises a suitable 
building shall be provided to be used for the isolation and quar- 
antine of persons under suspicion of having a contagious disease. 

The following plan of construction is recommended: 



APPENDIX. 653 

Tlie quarantine building and hospital should be one story high and con- 
tain at least two rooms, each with a capacity of about (5,000 cubic feet 
and contain not more than three beds each, the rooms to be separated by 
a closed partition. The doors opening into the rooms should be on op- 
posite sides of the building and provided with locks. The windows should 
be barred and the sash should be at least 5 feet from the ground and con- 
structed for proper ventilation. The walls should be of a material which 
will allow proper disinfection. The floor should be of painted or washable 
wood, preferably of concrete, and so constructed that the floor may be 
flushed and properly disinfected. Proper heating, lighting, and ventilating 
facilities should be provided. 

9J:. In the event of any illness of a suspicions nature the at- 
tending physician shall immediately quarantine the suspect, 
notify the health authorities and the secretary of the commis- 
sion, and examine each member of the dairy force, and in every 
inflammatory affection of the nose or throat occurring- among the 
employees of the dairy, in addition to carrying out the above- 
mentioned program, the attending physician shall take a culture 
and have it examined at once by a competent bacteriologist ap- 
proved by the commission. Pending such examination, the af- 
fected employee or employees shall be ciuarantined. 

95. It shall be the duty of the secretary, on receiving notice 
of any suspicious or contagious disease at the dairy, at once to 
notify the committee having in charge the medical supervision 
of employees of the dairy farm upon which such disease has 
developed. On receipt of the notice this committee shall as- 
sume charge of the matter, and shall have power to act for the 
commission as its judgment dictates. As soon as possible there- 
after, the committee shall notify the commission, through its 
secretary, that a special meeting may be called for ultimate con- 
sideration and action. 

96. When a case of contagious disease is found among the 
employees of a dairy producing certified milk under the control 
of a medical milk commission, such employee shall be at once 
quarantined and as soon as possible removed from the plant, 
and the premises fumigated. 

When a case of contagion is found on a certified dairy it is advised that 
a printed notice of the facts shall be sent to every householder using the 
milk, giving in detail the precautions taken by the dairyman under the 



654 THE DISEASES OF CHILDREN". 

direction of the commission, and it is further advised that all milk pro- 
duced at such dairy shall be heated at 145° F. for 40 minutes, or 155° F. 
for 30 minutes, or 167° F. for 20 minutes, and immediately cooled to 50° 
F. These facts should also be part of the notice, and such heating of the 
milk should be continued during the accepted period of incubation for 
such contagious disease. 

The following method of fumigation is recommended : 

After all windows and doors are closed and the cracks sealed by strips of 
paper applied with flour paste^ and the various articles in the room so 
hung or placed as to be exposed on all sides, preparations should be made 
to generate formaldehyde gas by the use of 20 ounces of formaldehyde and 
10 ounces of permanganate of potash for every 1,000 cubic feet of space to 
be disinfected. 

For mixing the formaldehyde and potassium permanganate a large gal- 
vanized-iron pail or cylinder holding at least 20 quarts and having a flared 
top should be used for mixing therein 20 ounces of formaldehyde and 10 
ounces of permanganate. A cylinder at least 5 feet high is suggested. 
The containers should be placed about in the rooms and the necessary 
quantity of permanganate weighed and placed in them. The formaldehyde 
solution for each pail should then be measured into a wide-mouthed cup 
and placed by the pail in which it is to be used. 

Although the reaction takes place quickly, by making preparations as ad- 
vised all of the pails can be "set off" promptly by one person, since there is 
nothing to do but pour the formaldehyde solution over the permanganate. 
The rooms should be kept closed for four hours. As there is a slight danger 
of fire, the reaction should be watched through a window or the pails placed 
on a noninflammable surface. 

97. Following a weekly medical inspection of the employees, 
a monthly report shall be submitted to the secretary of the med- 
ical milk commission, on the same recurring date by the exam- 
ining visiting physician. 

The following schedule, filled out in writing and signed by 
himself, is recommended as a suitable form for the attending 
physician 's report : 

This is to certify that, on the dates below indicated, official visits were 
made to the — dairy, owned and conducted by of (in- 
dicating town and State), where careful inspections of the dairy employees 
were made. 

(a) Number and dates of visits since last report. — ■ — ■ — •. 

(h) Number of men employed on the plant. . 

(c) Has a recent epidemic of contagion occurred near the dairy, and 
what was its nature and extent . 



APPENDIX. 655 

(d) Have any cases of contagious or infectious disease occurred among 
the men since the last report? 



(e) Disposition of such cases. 



(/) What individual sickness has occurred among the men since the last 
report? . 



ig) Disposition of such cases. . 

(h) Number of employees now quarantined for sickness. . 

(i) Describe the personal hygiene of the men employed for milking when 

prepared for and during the process of milking. . 

(./) What facilities are provided for sickness in employees? . 



(k) General hygienic condition of the dormitories or houses of the em- 
ployees. . 



(Z) Suggestions for improvement. . 

(m) What is the hygienic condition of the employees and their surround- 



ings 



(n) How many employees were examined at each of the foregoing visits 



( ) Remarks. 



Date, 



Attending Physician. 



INDEX. 



INDEX. 



Abdomeii, palpation of, 70 
Abscess, alveolar, 241 

symptoms, 241 

treatment, 241 
peritonsillar, 164 

etiology, 164 

symptoms, 164 

treatment, 165 

retropharyngeal, 161 

sjTnptoms, 161 

treatment, 165 
Abt, Isaac A., 316 
Acetone, odor in cyclic vomiting, 256 
in urine, 257, 327 

tests for, 257, 258 
Acid, boracic, in care of nipples, 88 
Adenoids, 165 

etiology, 165 

pathology, 165 

symptoms, 166 

treatment, 167 
and chronic rhinitis, 153 
and tnbo-tympanic catarrh, 175 
Adenitis, 470 
acute, 470 

definition, 470 

etiology, 470 

pathology, 470 

prognosis, 470 

symptoms, 470 

treatment, 471 
chronic, 471 

diagnosis, 472 

symptoms, 472 

treatment, 472 
and vaccination, 394 
in scarlatina, 383 
Addison's disease, 472 

diagnosis, 472 

pathology, 472 

prognosis, 472 

s^Tiiptoms, 472 

treatment, 472 
Adrenal glands, tuberculosis of, 472 
Adrenalin solution. 153 
Agriculture, Department of. Score 
cards, 122 



Agriculture, Dept. of — contd. 

condensed milk anaylsis, 132 
Ague, 346 
Albumin water. 141 
Albuminuria, 477 
cyclic, 478 
functional, 478 
intermittent, 478 
causes, 478 
diagnosis, 478 
etiology, 478 
pathology, 478 
prognosis, 478 
symptoms, 478 
treatment, 479 
Alcoholic beverages and breast milk, 
97 
stimulation in children, 76 
Allen, 118 

Alveolar abscess, 241 
Amaurotic family idiocy, 552 
Amygdalitis, acute lacunar, 159 
Anatomy of infants, 17 
Anemia, 455 
in rachitis, 508 
in rheumatism, 324 • 
infantum, 456, 464 
definition, 456 
diagnosis, 457 
etiology, 456 
pathology, 456 
prognosis, 457 
symptoms, 456 
treatment, 457 
pernicious, 456 
primary, 455 
secondary, 455 
symptomatic, 455 
Angina in scarlatina, 382 
Ani, sphincter, dilation of, in as- 
phyxia, 28 
Animal broths, 141 
Animal Industry, Bureau of, 122 
Ankylostoma duodenale, 291, 456 
description, 291 
diagnosis. 292 
prognosis, 292 
symptoms, 2til 



659 



660 



INDEX. 



Ankylostoma duodenale — contd. 

synonyms, 291 

treatment, 292 
Anodynes, 77 
Anopheles, 348 

Antibodies in antitoxin therapy, 421 
Antimony and ipecac tablets, 205 
Antipyretics, medicinal, 76 

bath as, 77 
Antitoxin, diphtheria, 412 

complications following, 421 

in diphtheretic conjunctivitis, 
193 
Anus, imperforate, in new-born, 30 
Aortic regurgitation, 444 

pathology, 444 

physieal signs, 444 

symptoms, 444 
stenosis, 445 

pathology, 445 

physical signs, 445 

prognosis, 446 

symptoms, •*45 
Aphthae, Bednar's, 234, 239 

etiology, 234 • 

pathology, 234 

symptoms, 234 
Aphthous stomatitis, 235 
Appendicitis, 296 

blood count in, 299 

definition, 296 

diagnosis, 300 

etiology, 296 

pathology, 296 

prognosis, 301 

symptoms, 298 

treatment, 301 

in typhoid fever, 316 
catarrhal, 296 

symptoms, 298 
gangrenous, 297 

symptoms, 299 
and pneumonia, 222 
sclerotic, 297 

symptoms, 300 
ulcerative, 297 

symptoms, 299 
Appendix, 598 
Aprosexia, 154, 166 
Argyrol solution, 153 

in eyes of new-born, 30 
Arneill, 24 
Arnold bottle, 124 
Arrowroot gTuel, 1*2 
Arteries, superior vesicle, 17 
Arthritis, 324 

diagnosis from rheumatism, 324 



Arthritis — conid. 

septic or tubercular, 324 
in scarlatina, 383 
Artificial foods, 148 
Ascaris lumbricoides, 289 
description, 289 
diagnosis, 290 
eggs of, 290 
symptoms, 290 
treatment, 290 
Ascites in mitral stenosis, 443 
Asphyxia, forms of, 25 
prognosis, 26 
symptoms, 26 
treatment, 26 
Aspirin in tonsillitis, 158 
Aspiration in pleurisy, 227 

empyemia, 230 
Asthma, 202 

etiology, 202 
physical signs, 202 
symptoms, 202 
treatment, 203 
Astigmatism, mixed, 187 
Ataxia, hereditary, 550 
diagnosis, 551 
etiology, 550 
pathology, 550 
prognosis, 551 
symptoms, 551 
treatment, 551 
Atelectasis, 44, 203 
etiology, 44, 203 
pathology, 44, 203 
symptoms, 44, 204 
treatment, 44, 204 
following asphyxia, 26 
Anthrepsia, 501 
diagnosis, 502 
etiology, 501 
pathology, 501 
prognosis, 503 
symptoms, 502 
treatment, 503 
Atrophy, Infantile, 501 
Auditory canal, diseases of external, 

172 
Ausculation, 70 
position for, 71 



Babcock, 129, 434, 436, 446 

milk tester. 129 
Babies, care of, in hot weather, 619 

Milk Fund Association of Louis- 
ville, Ky., 128, 619 

outfit, 32 
Baby, preparation for, 32 



INDEX. 



661 



Babinski's reflex, 65, 335, 515, 559 
Bacillus coli communis, 246, 212 

cyanogene, 105 

hay, 237 

Klebs-Loeffler, 116, 212 

lactis aerogenes, 246 

Pfeifter, 407 

Shiga, 246 

subtilis, 246 

tubercle and milk, 116 

typhoid and milk, 116 

viscosus, 105 

Week's, 189 
Bacteria in milk, 105, 117, 246 

lactic acid, in milk, 105 

of stomach and intestines, 246 
Bacterial count, method of, in milk, 

642 
Baeyer's test for acetone, 258 
Balanitis, 494 
etiology, 494 
symptoms, 494 
treatment, 495 
Ballantyne, 24 

Bauer's milk modification, 598 
Barley gruel, 139 
Barlow's disease, 504 
Barnes, H. A., 156 
Barnhill, 178, 183 
Basket, contents of baby's, 32 
Bassinet, 30 
Bastianelli, 347, 354 
Bath, 77 

bran, 79 

brine, 80 

mustard, 79 

Nauheim, 80 

soda, 79 

temperature, 31 

for temperature, 77 

thermometer, 77 

tub, 78 
Bathing of new-born, 31 
Bednar's aphthse, 234, 239 
Bed-wetting, 491 
Beef juice, 141 

scraped, 143 
Bein, 353 
Bell's palsy, 534 
Bengue analgesique balm, 325 
Benzoin in inhalations, 75 
Bermuda arrowroot, 142 
BcYan's operation for undescended 

testicle, 499 
Biceps jerk, 514 
Biedert, 136 

cream mixture, 135 



Bignami, 347, 353 
Bland Nuhn gland, 240 
Bleeder, 37, 467 
Blepharitis, 187, 189 
etiology, 187 
symptoms, 188 
treatment, 188 
Blisters, 77 
Blood, 451 

changes, general consideration of, 

454 
corpuscles, red, 453 

white, 453 
count in appendicitis, 299 
diseases, 451 
letting in nephritis, 486 
method of examination, 451 
picture in malaria, 353 
Bloom, I. X., 588 

Bone-marrow, in pernicious anemia, 
456 
in leukemia, 463 
Bordet, 39;J 
Bosses on bones, 509 
Bothriocephalus latus, 459 
Bottles, 124 
annealing, 124 
Arnold, 124 
care of nursing, 123 
hygeia nursing, 124, 147 
pasteurizing, 116 
Thermos, and milk, 114 
Whitehall Tatum, 124 
Bouzian, 353 
Bowles' stethoscope, 70 
Bradycardia, 448 
etiology, 448 
symptoms, 448 
Brain, abscess of, 572 
diagnosis, 572 
etiology, 572 
pathology, 572 
prognosis, 572 
symptoms, 572 
treatment, 573 
at birth, 24 
diseases of, 555 
tumors, 570 
diagnosis, 571 
etiology, 570 

localization symptoms, 571 
pathology, 570 
prognosis, 571 
symptoms, 570 
treatment, 571 
Bran bath, 79 



662 



INDEX. 



Branchial fistula, 242 

treatment, 242 
Breast-feeding, contra-indications to, 
88 
milk, amount at feeding, 92 
composition, 91 
examination, 91 
supervision, 94 
Brideau, 363 
Brill, 315 
Brine bath, 80 
Bright's disease, acute, 483 
Bronchial glands, at birth, 19 
tubes, 200 

foreign bodies in, 200 
diagnosis, 200 
symptoms, 200 
treatment, 201 
Bronchitis, acute catarrhal, 204 
diagnosis, 206 
from broncho-pneumonia, 206, 

215 
etiology, 204 
pathology, 205 
physical signs, 206 
prognosis, 206 
symptoms, 205 
treatment, 207 
capillary, 212 
chronic catarrhal, 209 
diagnosis, 210 
pathology, 209 
physical signs, 209 
prognosis, 210 
symptoms, 209 
treatment, 210 
and heart disease, 432 
in typhoid fever, 313 
Broncho-pneumonia, 212 
and heart disease, 342 
in typhoid fever, 313 
Broths, animal, 141 
Brown, 339 
Bruce, E. T., 201 
Bruit de diable, 459 
Buccal eruption of measles, 67, 369 
Budin, Pierre, 137 
Bureau of Animal Industry, 122 
Burns, Wm. Britt, 346 
Busey & Kober, 112 
Butterick's fashions, 33 
Buttermilk, 142 
Buttocks, 31 
Byrd-Dew Treatment of asphyxia, 27 

C 

Cabot, 299 



Calcium paracasein, 119 
Calculus, as cause of pyelitis, 479 

Renal, 481 
Calmette test in tuberculosis, 339 
Calomel vapor inhalations, 76 
Calorie, 138 

Camphor as a stimulant, 77 
Onncarem oris, 236 
Caput succedaneum, 17, 36 
Carbohydrates, 120 
Cascara excreted in milk, 90 
Casein, 119 

action of acid on, 119 

calcium, 119 

calculating amounts in herd 

milk, 145 
and citrate of soda, 145 
Cassellberry, 426 
Catarrh, acute gastric, 248 
nasal, 152 

of conjunctiva, vernal, 192 
Catarrhal pneumonia, 212 
Census report on milk, 115 
Cephalhematoma, differentiation 

from hernia cerebri, 436 
treatment of, 37 
Cereal gruels, percentage, 144 
Cerebral hemorrhage, 49, 573 

localization, 571 
Cerebral palsies, 567 
Cerebrospinal fluid in spotted fever, 

558 
Cerebrospinal sclerosis, 549 
Cereo, 138 
Certified milk, 100, 104 

methods and standards for produc- 
tion and distribution of, 632 
Cestodes, 293 

Chautard's test for acetone, 258 
Chapin, 85, 131, 476, 625 
cream dipper, 130 
urinal, 476 
Chest, regions of, 62, 63 
Cheyne Stokes respiration, 334, 563, 

571 
Chicken-pox, 389 
Chloral, 77 
Chlorosis, 458 

diagnosis, 459 
etiology, 458 
pathology, 458 
prognosis, 459 
symptoms, 459 
treatment, 459 
Cholera infantum, 266 
definition, 266 



INDEX. 



663 



Cholera infantum — contd. 
diagnosis, 267 
etiology, 266 
pathology, 266 
prognosis, 267 
symptoms, 267 
treatment, 268 
Chorea, 520 
electric, 525 
habit, 524 

diagnosis, 524 
symptoms, 524 
treatment, 524 
hereditary, 523 
etiology, 523 
prognosis, 524 
symptoms, 523 
treatment, 524 
minor, 520 

definition, 520 
etiology, 520 
pathology, 521 
symptoms, 521 
treatment, 522 
in typhoid feyer, 312 
posthemiplegic, 522 
and rheumatism, 323 
Sach's sign of, 65 
severe, 521 
Sydenham's, 520 
varieties, 520 
Christian, Frank L., 554 
Churchill-Loper, 402, 498 
Circulation at birth, 17 

fetal, 19 
Circulatory system, diseases of, 430 
Circumcision,' 32, 493, 495 
Citrate of soda in breaking up curds, 

145 
Clavicle at birth, 18 
Climate in bronchitis, 210 
Clubbing of fingers in mitral steno- 
sis, 443 
Coccus of trachoma, 190 
Cod-liver oil in condensed milk feed- 
ing,. 132 
Coit, Henry L., 100 
Colds, 165 
Colic, 259 

diagnosis, 261 
symptoms, 260 

treatment, during attack, 261 
preventive, 261 
in renal calculus, 482 
Colin, L., 358 
Colles' law, 362 
Colon, 282 



Colon — contd. 
dilation of, 282 
diagnosis, 286 
etiology, 282 
pathology, 283 
prognosis, 286 
symptoms, 283 
synonyms, 282 
treatment, 286 
giant, 282 
irrigation of, 84 
mega, 282 

bacillus of, cause of pyelitis, 479 
Colostrum, 87, 95 
analysis of, 95 
disagreement, 96 
Combined feeding, 99 
Comby, 472 
Comforter, 60 

Commission, Medical Milk, 632 
Compensation, in heart lesions, 441 

rupture of, 441 
Condensed milk, 131, 132 
Condylomata, 364 
Congenital heart lesions, 431, 432 
Conjunctiva, vernal catarrh of, 192 
Conjunctivitis, 189 
etiology, 189 
symptoms, 190 
treatment, 190 
diphtheritic, 193 
etiology, 193 
pathology, 193 
symptoms, 193 
treatment, 193 
granular, 192 

treatment, 192 
in measles, 365 
phlyctenular, 193 
etiology, 193 
prathology, 194 
symptoms, 194 
treatment, 194 
Connor's tables, milk modification, 

595 
Constipation, 278 
etiology, 278 
prognosis, 280 
symptoms, 279 
treatment, 280 
medicinal, 281 
Contagious diseases. 368 
incubation, 417, 426 
quarantine, 417, 426 
Convulsions, 518 
etiology, 518 
prognosis, 519 



664 



INDEX. 



Convulsions — contd. 
symptoms, 518 
treatment, 519 
Convulsive tie, 524 
Cor bovinum, 444 
Cord, umbilical, ligature, 29 
spinal, diseases of, 536 

syphilis of, 548 
umbilical dressing, 28 
family disease of, 550 
Corlett, 390 
Cornea, diseases of, 198 
opacity of, 191 
pannus of, 191 
ulcer of, 195 
Cornet, 331 

Corona glandis at birth, 23 
Corpuscles, red blood, 453 
Corrigan pulse, 444 
Corsets and depressed nipples, 87 
Cotton, A. C, 145 
Counter-irritants, 77 
in bronchitis, 207 
Councilman, 395 
Coutts, J. A., 216 
Cow-pox, 391 

Cows, unsuspected but dangerous 
tubercular, 110 
of different breeds, milk from, 118 
milk, 100 

milk and mother's milk, compara- 
tive analysis, 100 
Cowlings, rule for dosage, 74 
Cragin method of milk modification, 

606 
Craniotabes, 364, 508 
Cream dipper, 130 

and whey feeding, 134 
mixture, Biedert, 135 
Crede's treatment of eyes, 30 
Cremaster reflex, 514 
Cretinism, 473 

definition, 473 
diagnosis, 473 
etiology, 473 
pathology, 473 
prognosis, 474 
symptoms, 473 
treatment, 474 
Crocker, 592 
Crofton, 477, 478, 479 
Croup, 168 

diagnosis, from diphtheria, 169, 

418 
inhalation in, 75 
kettle, 170 
spasmodic, 168 



Cry, child's, 64, 65 

Cryptorchid, 24, 499 

Cups, dry, in nephritis, 486 

Curds in infant stools, 144 

Cushing, 543 

Cutaneous diagnosis tuberculosis, 

340 
Cyclic vomiting, 256 

diagnosis, 257 

etiology, 256 

prognosis, 258 

symptoms, 256 

treatment, 258 
Cyst, branchial, 242 
Cystitis, 498 

prognosis, 498 

symptoms, 498 

treatment, 499 

D 

Da Costa, 506 

Dactylitis in lues, 363 

Dairies, inspection of, 122 

Deming milk modifier, 604 

Dermographism, 596 

Dentition, 57 

Dermatitis herpetiformis, diagnosis 

from pemphigus, 587 
Development in growth, 53 
Dextrinizing agents, 138 
Diabetes mellitus, 326 
complications, 328 
definition, 326 
diagnosis, 328 
etiology, 327 
frequency, 327 
pathology, 327 
prognosis, 328 
symptoms, 327 
treatment, 328 
Diagnostic methods in nervous dis- 
eases, 513 
Diarrhea, from milk, 115 

inflammatory, 269 
Diazo reaction, 314 
Diet after first year, 146 

from twelfth to fifteenth month, 

147 
from fifteenth to eighteenth 

month, 147 
of nursing mother, 89 
to be avoided after first year, 147 
Digestive system, diseases of, 233 
Digitalis in heart lesions, 433 
Diluents in milk formulae, 138 
Diphtheria, 410 

diagnosis, 160, 417 



INDEX. 



665 



Diplitheria — con id. 

bacteriological. 41(5 
from croup, 109 
from tonsillitis, 160, 418 
antitoxin. 412 
bacteriology, 410 
casts, 416 ' 
chart of, ^114 
complications, 417 
complications followinQ- antitoxin. 

421 
and heart disease. 431 
quarantine in, 427 
cause of nephritis in. 483 
epidemics and milK, 114 
etiology. 410 
membrane in, 411 
pathology, 413 
quarantine in, 427 
symptoms, 414 
treatment, 419 
curative, 420 
general, 421 
local, 422 
medicinal. 421 
prophylactic. 419 
prognosis, 419 
Dipper. Chapin cream, 130 
Diseases, of blood, 451 
circulatory. 430 
contagious, 368 
digestive system, 233 
ear, 172 

foot and mouth, 116 
general, 307 

genito-urinary system, 476 
hookworm. 291 
larynx, 152 
lymphatic gland, 469 
nervous system. 513 

diagnostic methods in, 513 
functional, 518 
nose. 152 
Pott's, 545 

X-ray of, 546 
spinal cord, 536 
stomach and intestines, 245 
throat, 152 
wasting, 501 
Disinfection, 429 
Disorders of sleep, 531 
Distichiastis, 191 
Dobell's solution, 154. 161, 176 
Dochez, 536 
Draper, 536 

Dropsy in mitral regurgitation, 434 
Drugs excreted by breast, 96 



Dul)ini. 525 
Duchek, 353 
Dunlop, 216 
Dunn, 561 
Dysentery. 269 
Dyspnea, and heart disease, 432 
Dyspepsia, acute, 248 
Dvstroi^hy. progressive muscular, 
552 

E 

Eager. 115 
Ear, diseases of, 172 
infant's, 18 
middle, 174 

examination, 08 
inflammations of, 175 
specula, 68 
Eberth, 308 
Ectropion, 191 
Eclampsia, infantile, 518 
Eczema, 590 

etiology, 590 
pathology, 590 
prognosis, 592 
symptoms, 590 
treatment, 592 
erythematosum, 591 
papulosum, 591 
pustulosum, 592 
squamosum, 592 
vesiculosum, 591 
Eczematous conjunctivitis, 193 
Edebohls, Geo. M., 487 
Edwards. 35 
Ehrlich. 367. 464 
Electric examinations in nervous 

diseases, 515 
Emmetropia, 187 
Emphysema, 210 

compensation in, 211 
etiology, 211 
pathology, 211 
symptoms, 211 
treatment. 211 
and pertussis. 395 
Empyema. 228 

diagnosis, 229 
etiology. 228 
pathology, 228 
physical signs, 229 
prognosis. 230 
symptoms. 228 
treatment. 230 
after. 231 
Encephalitis, acute, 563 
etiolog}', 563 



666 



INDEX. 



Encephalitis — contd. 
pathology, 563 
prognosis, 564 
symptoms, 563 
treatment, 564 
Endocarditis, 438 
etiology, 438 
pathology, 438 
physical signs, 439 
prognosis, 439 
symptoms, 439 
treatment, 439 
chronic, 441 

pathology, 441 
fetal, 432 
malignant, 440 
etiology, 440 
pathology, 440 
prognosis, 441 
symptoms, 440 
treatment, 441 
Enemata, 74 

nutrient, 74 
Enteric fever, 307 

infection, 269 
Enteritis, 269 

from milk, 115 
Enterocolitis, acute, 269 

course and duration, 272 
diet, 264 
etiology, 269 
hygiene, 266 
pathology, 269 
prognosis, 272 
symptoms, 271 
treatment, 273 
general, 273 
hygienic, 275 
medicinal, 274 
preventive, 272 
chronic, 275 
diagnosis, 276 
pathology, 276 
prognosis, 277 
symptoms, 276 
treatment, 277 
dietetic, 277 
hygienic, 277 
medicinal, 278 
Enterocolysis, 76 
Entropion, 191 
Enuresis, 491 

definition, 491 
etiology, 491 
prognosis, 491 
symptoms, 491 
treatment, 491 



Eosinophils, 454 

Eosinophilia, 455 

Epidemics due to milk, 112, 113, 114 

Epilepsy, 527 

diagnosis, 529 
etiology, 528 
pathology, 528 
symptoms, 528 
treatment, 530 
Epistaxis, 154, 155 
etiology, 155 
prognosis, 530 
symptoms, 155 
treatment, 156 
in atrophic rhinitis, 154 
Epithelial desquamation of tongue, 

233 
Epstein, 82, 83 
Erb's paralysis, 535 

type of muscular dystrophy, 552 
Erysipelas complicating varicella, 

383 
Erythema multiforme, diagnosis 
from pemphigus, 587 
nodosum, 323 
in rheumatism, 324 
Esophagitis, 242 
symptoms, 242 
treatment, 243 
Esophagus, five cent piece in, 201 
Eustachian tubes at birth, 18 

valve, 19 
Ewing, 356 
Examination, methods of, 62 

physical, in pediatrics, 62 
Exanthemata, cause of nephritis, 
485 
acute, 308 
Extremities, upper and lower at 

birth, 16 
Extubation, 426 

Eye, Crede's treatment of the, 29, 
195 
diseases of the, 187 
pink, 189 
Eyelids, method of everting, 187 
Eye-strain, 187 

F 
Facial palsy, 534 
Family disease of cord, 550 
Fat, Babcock's test for, in milk, 129 
disease of, in breast feeding, 97, 

98 
disagreement of, in breast milk, 97 
increase of, in breast feeding, 97, 
98 



INDEX. 



667 



Fat — contd. 

in milk, 120, 129 
too much, in milk feeding, 144 
Favus, 580 
Feces, 247 
Feeding, artificial. 99 

breast, supervision of, 94 
combined, 99 
difficult cases, 145 
infant, 87 
by rectum, 150 

jjosition for, in intubation cases, 
425 
Fetal, circulation, 19 

heart, condition of, in heterotaxia, 
9 
Fever, blister, 593 

chart in, diphtheria, 414 
lobar pneumonia, 219 
malarial hemoglobinuria, 358 
measles, 370 
German, 377 
and pneumonia, 371 
pemphigus, 589 
typhoid fever, 310, 312 
tuberculosis, 333 
intermittent, 346 
lung, 218 
rheumatic, 322 
scarlet, and milk, 112 
typhoid, 307 
and milk, 113 
Finney, J. M., 285 
Fistula, of neck, 242 
symptoms, 242 
treatment, 242 
Fleckern, 368 
Flexner, 561 

Flora, bacterial, in intestines, 247 
Fontanelles, 17 
Food, artificial, 148 
proprietary, 148 
strength of, for different months. 

146, 147 
to be avoided, 148 
Foot and mouth disease. 116 
Foramen ovale, patency of, 432 
Forceps, high, 47 

Foreign bodies in bronchial tubes. 
200 
diagnosis, 200 
svmptoms, 200 
treatment^ 200 
matter in milk, 104 
Fotzke, 549 
Foulouse, 531 
Fraenkel, 399 



Francisco, Stephen, 100 

Friedreich's disease, 550 

Frontal bone at birth, 17 

Fuller, 468 

Functional disorders of the heart, 

448 
Furunculosis and diabetes mellitus, 
328 
of external auditory canal, 172 
etiology, 172 
pathology, 172~ 
symptoms, 172 
treatment, 172 

G 
Gaertner's mother's milk, 149 
Gangrene of cheek, 236 
of" lung, 231 

etiology, 231 

pathology, 231 

physical signs, 232 

symptoms, 232 

treatment, 232 
Gargles, 75 
Garrod, 521 
Gastralgia, 262 

diagnosis, 262 

symptoms, 262 

treatment, 262 
Gastrectasia, 255 
Gastric catarrh, acute, 248 

diagnosis, 249 

etiology, 248 

pathology, 248 

prognosis, 249 

symptoms, 248 

treatment, 249 
dilatation, 255 

etiology, 255 

pathology, 255 

prognosis, 255 

symptoms, 255 

treatment, 255 
disorders, 248 
indigestion, acute, 248 
Gastritis, acute, 248, 251 

etiology, 251 

pathology, 251 

prognosis, 251 

symptoms, 251 

treatment, 251 
chronic, 25.2 

diagnosis, 253 

etiology, 252 

pathology, 252 

prognosis, 252 

treatment, 252 



668 



INDEX. 



Gastro-eiiteric infection, acute, 2G3 
etiology, 263 
pathology, 263 
prognosis, 264 
symptoms, 264 
treatment, dietetic, 264 
hygienic, 266 
medicinal, 265 
prophylactic, 264 
Gastro-enteritis, 263 
Gastro-intestinal hemorrhage, 40 

indigestion, 275 
Gavage, 149 • 
Gelatin in hemorrhage, 41 
Gengou, 399 

Genitals, care of, in new-born, 32 
Genito-urinary system, disease of, 

476 
Genu-valgumin rachitis, 509 
Genii-varum in rachitis, 509 
Geographical tongue, 234 
German measles, 376 
quarantine in, 428 
Glands, bronchial, at birth, 19 
lymphatic, diseases of, 469 
suprarenal, at birth, 21 
thymus, at birth, 19, 469 
tuberculosis, 229 
Glioma, 570 
Globus hystericus, 526 
Golgi, 521 

Gonorrheal infection of mouth, 239 
Grand mal, 528 
Granulated lids, 190 
Graves' disease, diagnosis from 

tachycardia, 449 
Griffiths, 316 
Grip, 407 
Groff, A., 346 
Growing pains, 322 
Growth and development, 53 
Gruels, 97, 139 
arrowroot, 142 
Keller's method of dextrinizing, 

138 
percentage cereal, 144 
Guiseppe, 240 
Gummata, 365 

H 
Hair of new-born, 35 
Hale's method of milk modification, 

610 
Hamilton's method of milk modifica- 
tion, 601 
Hart, E., 119 
Hay, bacillus, 245 
Hay em, 453 



Head, at birth, 17 
moulding of, 17 
Headache in eye-strain, 187 
Heart, 430 

congenital lesions, 431 
defects, 430 
diagnosis, 432 
diseases of, 430 
etiology, 431 
prognosis, 433 
symptoms, 432 
treatment, 433 
auscultation of, 72 
fetal, 19 

functional disorders, 448 
in heterotaxia, 24 
involvement in rheumatism, 431 
Heat, effect of, on milk, 117 
Heine, 536 

Hemic murmurs, 457 
Hematuria in purpura, 459 
Hemiplegia, spactic, 567 
Hemoglobin in chlorosis, 458 
pernicious anemia, 456 
pseudo-leukemia, 465 
scale, Dare's, 452 
Tallquist, 452 
Hemoglobinometer, Von Fleischel's, 
452 
Oliver's, 452 
Hemophilia, 37, 467 
diagnosis, 468 
etiology, 467 
pathology, 468 
prognosis, 468 

symptoms, 468 * 

treatment, 468 
Hemorrhage : 

cerebral, 49, 565 
etiology, 573 
prognosis, 573 
symptoms, 573 
in cord, diagnosis from myelitis, 

544 
intra-cranial, 573 
subdural, 573 
of new-born, 38 
etiology, 39 
location, 39 
prognosis, 41 
treatment, 41 
in typhoid fever, 312 
umbilical, 37 
Henoch, 41 

purpura, 467 
Hereditary, ataxia, 550 
spastic paralysis, 551 



INDEX. 



669 



Hereditary in malaria, 353 

and leukemia, 461 
Hernia, umbilical, 20, 42 
cerebri, 36 
contents of, 43 
in pertussis, 400 
treatment of, 43 
Herpes, 593 
facialis, 594 
zoster, 594 

definition, 594 

diagnosis, 595 

etiology, 594 

symptoms, 594 

treatment, 595 
in rheumatism, 324 * 
Herz's arm test in rheumatism, 322 
Heterotaxia, 24 
Hess refrigerator, 631 
Heubner, 136 
High forceps, 47 
Hirschprung-'s disease, 282 
History card, 64 
Hives, 596 

Hodgkins' disease, 464, 472 
Holt, 35, 91, 93, 142, 566 
Holt's milk set, 91 
Hookworm disease, 291 
Hordeolum, 188 

etiology, 188 

symptoms, 188 

treatment, 189 
Horse serum, 468 
Hospital, sick children, 216 
Huntington's chorea, 523 
Hydrocele, 494 

definition, 494 

symptoms, 494 

treatment, 494 
Hydrocephalus, acute, 564 

etiology, 564 

pathology, 564 

prognosis, 564 

symptoms, 564 

treatment, 565 
chronic, 565 

diagnosis, 567 

etiology, 565 

prognosis, 567 

symptoms, 565 

treatment, 567 
Hydronephrosis, 490 

definition, 490 

etiology, 490 

pathology, 4{)0 

prognosis, 490 

symptoms, 490 



Hydronephrosis — contd. 

treatment, 490 
Hydrothorax, 438 

menstruation in, 73 
Hygiea bottle, 124 
pasteurizer, 116 
Hyperopia, 187 
Hypodermoclysis, 76 
Hysteria, 525 

diagnosis, 526 
etiology, 525 

motor manifestations, 526 
sensory manifestations, 525 
symptoms, 525 
treatment, 527 
in chlorosis, 459 
mental manifestations, 526 
Hysterical mania, 527 



Icterus in new-born, 44 
etiology, 45 
symptoms, 45 
treatment, 45 
Idiocy, Lorain type, 474 

Mongolian, 473 
Ileocolitis, 269 
Imperial granum, 148, 149 
Impetigo, contagiosa, 585 
diagnosis, 585 
etiology, 585 
pathology, 585 
symptoms, 585 
treatment, 586 
Inanition, 501 

Incubation and quarantine of con- 
tagious diseases, 426 
Indigestion, diagnosis from appendi- 
citis, 300 
acute gastric, 248 
Indigo test, 258 
Infant feeding, 87 

care of, in hot weather, 619 
Infantile paralysis, 536 
Infantilism, diagnosis from cretin- 
ism, 474 
of Lorain type, 474 
Infectious diseases cause of heart 

lesions, 431 
Infiuenza, 407 
Inhalation, 75 

calomel vapor, 76 
Injuries to new-born, 47 
Inoculation treatment in vulvo- 
vaginitis, 497 
Inspection of child, 64 
Insufflation in asphyxia, 27 



670 



INDEX. 



Insular sclerosis, 549 
Intertrigo, 16, 575 
treatment, 575 
Intestinal parasites, 287 
Intestines, 245 
bacteria of, 245 
disease of, 245 
surgical condition of, 296 
tuberculosis of, 329 
Intubation, 422 
indications, 423 
operation, 424 
position for operation, 425 
position for feeding in, 425, 426 
Intussusception, 302 
diagnosis, 304 
etiology, 303 
pathology, 302 
prognosis, 305 
symptoms, 303 
treatment, 305 
palpation of rectum in, 70 
Intussusceptum, 302 
Intussuscipiens, 302 
Inunction, 86 

lodiform test for acetone, 257 
Irrigation of colon, 84 
Iron persulphate in umbilical hemor- 
rhage, 37 
Itch, 578 



Jackson, 202 
Jacksonian epilepsy, 529 
Jacobi, 331 
Jellv, oatmeal, 143 
Jeniier, Edw., 391 
Juice, beef, 141 
Junket, 134, 140 
Hansen tablets, 141 

K 
Kahn, Lee, 416 
Keating, 35 

Keller's malt soup, 138 
Kelly, 301 

Keloid and vaccination, 394 
Kentucky's law and certified milk, 
"^101 
Agricultural College, 128 
Keratitis, phyctenular, 198 
etiology,' 198 
symptoms, 198 
treatment, 198 
interstitital, 199 
pathology, 199 
symptoms, 199 



Kerley, 80, 90, 132, 138, 140, 320, 

628 
Kernig's sign, 65, 335, 515 

in cerebrospinal meningitis, 559 
Kettle, croup, 170 
Kidneys, at birth, 20 
tumors, 488 
diagnosis, 489 
etiology, 489 
prognosis, 489 
symptoms, 489 
treatment, 490 
benign, 488 
decapsulation of, 487 
sarcoma, 488 
stone in, 481 
tuberculosis, 330 
Killain, 202 
Kilmer, T. W., 64, 404 
King, 347 
Klebs-Loeffler bacillus, 116, 175, 

410 
Klimenco, 399 
Knee-jerk, 514 
Kober and Busey, 112 
Koch, 108, 339 ^ 
Koplik, 41, 369 
spots, 67, 369 
Kumyss, 142 
Kupfer's cells in malaria, 355 



Laboratory milk, 128 

Walker 'Gordon, 125 
Laborde treatment of asphyxia, 28 
Lactalbumin, 120 
Lactation history, 96 
Lactic acid bacteria, 105 
Lactoglobulin, 120 
Lactone tablets, 142 
Ladd's cereal decoction, 140 

tables milk modification, 607 
La grippe, 407 

complications, 408 
diagnosis, 409 
etiology, 407 
pathology, 407 
prognosis, 409 
symptoms, 407 
treatment, 409 
and heart disease, 431 
Landouzy-Dejerine type of muscular 

dystrophy, 552" 
Landry, 538 
La Noble's test for acetone, 258 
Langhan's cells, 363 



INDEX. 



671 



Larrier, Nathan, 363 
Laryngitis, acute catarrhal, 168 
diagnosis, 169 
etiology, 168 
prognosis, 169 
symptoms, 169 
in measles, 372 
Laryngismus stridulus, 169, 510 
Larynx at birth, 18 

diseases of, 152, 168 
Laveran, 347 
Leach, 118 
Leeches, 186 
Leishman's stain, 351 
Lemon juice as styptic, 155 
Leucocytes, degenerated, 453, 454 

number of, 454 
Leucocytosis in appendicitis, 299 
in pertussis, 402 
neutrophilic, 455 
Leucopenia, 455 
Leucorrhea in chlorosis, 459 
Leukemia, lymphatic, 461 
Levy, 307 

Lieben's test for acetone, 257 
Liebig's foods, 149 
Lichen urticatus, 596 
Lips, disease of, 233 
Liver, at birth, 20 
Lockjaw, 49 
Loeffler's solution, 158, 161 

stain typhoid bacillus, 308 
Lorain type idiocy, 474 
Lues, 361 
Lumbar puncture, 516 

in cerebrospinal meningitis, 518, 

561 
in tubercular meningitis, 335, 516 
Lumbricoides, ascaris, 289 
Lungs, at birth, 18 
gangrene of, 231 
Lymphatic glands, disease of, 469 
leukemia, 461 
acute form, 461 
definition, 461 
etiology, 461 
myeloid, 461 

diagnosis, 462 
pathology, 462 
prognosis, 462 
symptoms, 462 
treatment, 462 
chronic form, 462 
diagnosis, 463 
etiology, 462 
pathology, 463 
prognosis, 463 



Lymphatic glands — contd. 

symptoms, 463 

treatment, 463 
Lymph at ism, 501 
Lymphocytes, -453 
Lymphocytosis, 455, 464 
Lymphoma, 464 

. M 
McBurney, 299 
McElroy, 346 
McKennon, Jas. F., 68 
Mabbott, 96 
Macewen's s: 
Malaria, 346 

definition, 346 
etiology, 347 
pathologj^, 354 
symptoms, 356 
treatment, 360 
and anemia, 447 
blood picture in, 353 

hemoglobinuria, 358 
heredity, 353 
historical note, 346 
prophylaxis, 359 
staining, 351 
susceptibility, 354 
in typhoid fever, 316 
Mai, grand, 528 

petit, 528 
Malnutrition, 501 
Malt soup, 138 
Malted milk, 149 
Mania, hysterical, 526 
Manson, 347 
Marasmus, 501 
Maseru, 368 
Mason, 369 
Masonic Widows' and Orphans' 

Home, 60 
Mast cells, 454 
Mastitis, in new-born, 47 
prognosis, 47 
symptoms, 47 
Mastoid cells at birth, 18 
Mastoiditis, 185 
diagnosis, 185 
etiology, 185 
prognosis, 185 
symptoms, 185 
treatment, 186 
Masturbation and thread worms. 287 
Materna, Hass, 603 
jNlaurer, 353 

Maxilla, inferior at birth, 18 
Mays, 223 



672 



INDEX. 



Measles, 368 

buccal eruption of, 67 
complications and sequelae, 372 
definition, 368 
diagnosis, 373 

from rubella, 373 
from drug eruptions, 374 
from scarlatina, 374 
etiology, 368 
eruption, 370, 369 
prognosis, 373 
symptoms, 369 
synonyms, 368 
treatment, 374 
. atypical cases, 371 
German, 376 
malignant, 371 
quarantine, 427 
Measurements chest and head, 55 
Meconium, 238 

ditTerentiation from melena, 25 
passage of, in asphyxia, 26 
Medicinal antipyretics, 76 
Mega colon, 288 
Megaloblasts, 453 
Megalocytes, 453 
Melena, 505 
Mellin's food, 148, 149 
Meninges, tuberculosis of, 32 
tumors of, 333 
diagnosis, 335 
etiology, 333 
pathology, 333 
prognosis, 335 
symptoms, 333 
treatment, 335 
Meningitis, epidemic cerebrospinal, 
518, 556 
bacteriology, 556 
diagnosis, 561 
etiology, 556 
pathology, 557 
prognosis, 557 
quarantine in, 428 
symptoms, 557 
treatment, 561 
and lobar pneumonia, 222 
simple acute, 555 
diagnosis, 556 
etiology, 555 
pathology, 555 
prognosis, 556 
symptoms, 555 
treatment, 556 
tubercular, 332 
diagnosis, 335 
etiology, 332 



Meningitis, tubercular — contd. 
pathology, 332 
prognosis, 335 
symptoms, 333 
treatment, 335 
Meningococcus, 557 
Menstruation, 60 

and epistaxis, 155 
changes in, in chlorosis, 459 
Mensuration, 73 
Methods of examination, 62 
Microblasts, 453, 456 
Micrococcus lanceolatus, 433 
Microcytes, 453 
Microsporon audonini, 580 
Microsporosa trachomatorum, 191 
Middle ear, examination, 68 
Miliaria, 324, 576 

Milk, analysis of different animals, 
118 
analysis of, by Babcock, 129 

by Van Slyke, 121 
bacteria in, 101, 246 
bacterial count, 105 
blue discoloration, 105 
box for collecting samples, 107 
breast, 90 

coming of, 87 
composition of, 91 
examination of, 91 
too small amount of, 91 
care of in home, 114 

on journey, 146 
casein, 119 

cause of epidemics, 112 
certified, 100, 104 

and Kentucky law, 102 
package, 104 
shiping case, 106 
changes in, caused by bacteria, 

105 
clean and cold, 104 
combined cows' and breast feed- 
ing, 98, 99 
commissions, American Associa- 
tion Medical Milk, 100, 632 
Jefferson county Medical ,100 
Kentucky law regulating, 101 
New Jersey law, 100 
New York, 100 
composition of, 117 
condensed, 131 

analysis, 131, 132 
cause of rachitis, 507 
cow's, 100 

and human, comparative analy- 
sis, 100, 132 



INDEX. 



673 



Milk, cow's — contd. 

of different breed, 118 

one, 99 
diluents in, 138 
diphtheria due to, 114 
,and distillery waste, 108 
effect of heat on, 117 
epidemics due to, 112 
fat in, 120 

estimate of, 129 
feeding, symptoms of disagree- 

nient of, 144 
foreign matter in, 104 
heat, effect of, 117 
influence of, on mortality statis- 
tics, 115 
market, 108 
mothers' and cows' comparative 

analysis, 100 
modifications, 598 

Babies' Milk Fund Association, 
629 

Bauer's formulae, 598 

Chapin formulae, 625 

by Deming modifier, 604 

by Hass Materna, 603 

Connor's tables, 602 

Hamilton's, 601 

Holt, 626 

Kerley, 628 

Ladd's tables, 607 

Moffitt's method, 615 

Sloane maternity milk set, 603, 
606 

Westcott's formula, 599, 601 
modified, 98, 125, 625 

laboratory, 125 

sugar in, 131 
morbidity and mortality statis- 
tics, influenced by. 115 
mother's supply of, 97, 98 
pail, hooded, 106 
pasteurization, 116 
peptonized, 133 
protein, 140 
• salts, inorganic, in, 122 
score, cards, 122 
set. Holt's, 91 
slimy and ropy, 105 
sterilization, 116 
and scarlet fever, 113 
and tuberculosis, 108 
and typhoid fever, 113 
top, 120 
Mitchell, Weir, 521 
Mitral regurgitation, 442 

pathology, 442 



Mitral regurgitation — contd. 
physical signs, 442 
prognosis, 443 
symptoms, 442 
stenosis, 443 
pathology, 442 
physical signs, 443 
prognosis, 443 
symptoms, 443 
Modified milk, 125 

prescription blank, 125, 126 
Mohler, 109 
Moncorvo, 358 
Mongolian idiocy, 473 
Monorchid, 24 
Morbilli, 368 
Morbus maculosis, 466 

ceruleus, 432 
Moro reaction in tuberculosis, 341 
Morrow, 365 
Morse, 508, 515 
Mortality statistics influenced by 

milk, 115 
Morton, 347 
Mosenthal, 400 
Moulding of head, 17 
Mouth, breathing, 166 
care of, in new-born, 31 
disease, 233 
examination, 67 
gonorrheal infection, 239 
symptoms, 239 
treatment, 239 
ulceration at angles of, 233 
Mother, nursing, 89 
diet of, 89 
milk of, 87 
Muguet, 238 
Mumps, 405 

Murphy's saline injection, 151 
Muscular dystrophy, progressive, 552 
etiology, 552 
pathology, 552 
prognosis, 554 
symptoms, 552 
treatment, 554 
Mustard bath, 79 
plasters, 77, 81 
Muutermilch fungus, 191 
Mya's disease, 282 
Myelitis, acute, 543 
diagnosis, 544 
etiology, 543 
pathology, 543 
prognosis, 544 
symptoms, 543 
treatment, 544 



674 



INDEX. 



Myelocyte, 454 
Myocarditis, a<;ute, 449 

etiology, 449 

pathology, 449 

prognosis, 450 

symptoms, 450 

treatment, 450 
Myopathy primary, 552 
Myopia, 187 
Myxedema, 473 

N 

Napkins, care of, 34 

rubber, 31 
Nasal catarrh, 152 
polypi, 156 

symptoms, 156 
treatment, 156* 
Nasopharynx at birth, 18 
Nauheim, Schott baths, 80 
Neck, fistula of, 242 
Neisser, 239 

Neonatorum ophthalmia, 195 
Nephritis, acute parenchymatous, 
483 
complications in, 485 
etiology, 483 
pathology, 484 
prognosis, 485 
symptoms, 484 
treatment, 485 
diet, 485 
medicinal, 485 
management, 485 
prophylaxis, 485 
chronic interstitial, 488 
etiology, 488 
pathology, 488 
prognosis, 488 
symptoms, 488 
treatment, 488 
chronic parenchymatous, 486 
diagnosis, 487 
etiology, 486 
pathology, 486 
prognosis, 487 
symptoms, 486 
treatment, 487 
Nerves, diseases of peripheral, 533 
Nervous system, diseases of, 513 
diseases, organic, 533 
diagnostic methods in, 513 
functional disorders, 513 
Nestle "s Food, 149 
Nettle rash, 596 
Neucleoalbumin in urine, 477 
Neuritis, multiple, 533 
etiology, 533 



Neuritis — con td. 

pathology, 533 

prognosis, 534 

symptoms, 533 

treatment, 534 
Neusholme, 115 
New-born, 25 

atelectasis in, 44 

bathing, 31 

care of, 28 

diseases of, 36 

dressing of, 32 

examination of, 30 

hair of, 35 

hemorrhage of, 38 

icterus in, 44 

injuries of, 36, 47 

mastitis in, 45 

sepsis of, 45 

skin of, 35 

starvation temperature in, 49 

temperature of, 35 

umbilical hernia, 20, 42 

urine of, 35 
Newman, 112 

New York Infant Asylum, 566 
Nipple, care of, 87, 88, 123 
cracked or eroded, 87 
Mai bott's treatment, 96 
shieM, 87 

li aining of depressed, 87 
Nodules, subcutaneous, in rheuma- 
tism, 322 
Noma, 236 
Normoblasts, 453 
Nose at birth, 18 

diseases of, 152 

examination of, 69 

foreign bodies in, 53 

irrigation of, 82 
Nott, 347 
Nurse, wet, 98 
Nursery, 34 

air space of, 19 

scales, 54 

temperature of, 34 
Nursing, bottles, 123 
contraindications to, 88 
interval at birth, 87 
method of, 90 
mother, 89 

bowels of, 90 

diet of, 89 

schedule of, 88 
Nutritional disorders, 501 

O 

Oatmeal jelly, 143 



INDEX. 



675 



O'Dwver, Jos., 167, 422 

intubation set, 423 
Olein in milk, 120 
Oliver's hemoglobinometer, 452 
Ophthalmia neonatorum, 195 
etiology, 195 
case of, 196 

focal symptoms, 195 
prognosis, 196 
prophylaxis, 195 
sequelae, 195 
treatment, 196 
Ophthalmic test in tuberculosis, 339 
Oppenheim, 549 
Optic neuritis, 571 
Osteomyelitis following tonsilitis. 
160 
diagnosed from rheumatism, 324 
Otitis media, in typhoid fever. 312 
acute catarrhal, 177 
etiology, 177 
pathology, 177 
prognosis, 178 
symptoms, 177 
treatment, 178 
acute suppurative, 179 
etiology, 179 
prognosis, 182 
s\Tnptoms, 181 
treatment, 182 
differential diagnosis of, 183 
in measles, 372 
in scarlatina, 382 
temperature curve of, 180 
Outfit for baby, 18 
Ovaries at birth, 24 
Oxyuris vermicularis, 287 
description, 287 
diagnosis. 288 
eggs of, 288 
symptoms, 288 
treatment, 288 
Ozena, 154 

P 
Pack, wet cool, 80 
Palmitin in milk, 120 
Palpation, 69 
Palsies, cerebral, 569 
diagnosis, 568 
etiology, 567 
pathology, 568 
prognosis, 568 
symptoms, 568 
treatment, 569 
Palsy, Bell's 534 
facial, 534 

diaonosis, 535 



Palsy, facial — contd. 
etiology, 534 
prognosis, 535 
symptoms, 535 
treatment, 535 
Paludism, 346 
Pannus of cornea, 191 
Paquelin cautery in cancrum oris, 

237 
Paracasein calcium, 119 
Paracentesis of drum, 176. 179 
Paraphimosis, 493 
treatment, 493 
Paraplegia, spastic, 567 

in syphilis of cord, 548 
Paralysis, hereditary, spastic, 551 
cerebral type, 551 
cerebrospinal type, 552 
diagnosis, 552 
prognosis, 552 
treatment, 552 
Erb's, 535 

prognosis, 535 
treatment, 535 
infantile, 536 
obstetrical, 535 
spinal type, 551 
diagnosis, 552 
prognosis, 552 
treatment, 552 
Parasites, benign tertian of malaria, 
350 
estivoautumnal, of malaria, 351 
intestinal, 287 
varieties, 287 
quartan of malaria, 350 
Parasitic skin lesions. 576 
Park, 351 
Parker, 412 
Parotitis, 405 

complications, 406 
etiology, 405 
prognosis, 406 
quarantine in, 429 
symptoms, 406 
treatment of, 406 
Pasteurization of milk, 116 
Pasteurized milk, bacteria in, 116 
Patterns for baby's clothes, 33 
Payor nocturnus. 532 
Peabody, 536 
Pediculosis, 576 
capitis, 576 
diagnosis, 577 
treatment, 577 
corporis, 577 
diagnosis, 578 



676 



INDEX. 



Pediculosis, corporis — contd. 

treatment, 577 
pubis, 578 
Peliosis rheumatica, 324 
Pellagra, 343 

diagnosis, 345 

etiology, 343 

pathology, 345 

prognosis, 346 

symptoms, 344 

treatment, 346 
Pemphigus vulgaris, acute, 586 

diagnosis, 587 

etiology, 586 

pathology, 586 

symptoms, 587 

treatment, 587 
chart of, 589 
foliaceous, 586 
neonatorum, 587 
vegetans, 586 
Peptogenic milk powder, 148, 149 
Peptonized milk, 133 
Percentage system of feeding, 125 
Percussion, 72 
hammer, 73 
Perforation in typhoid fever, 312 
Pericarditis, 433 

diagnosis, 435 

etiology, 433 

forms, 433 

pathology, 434 

physical signs, 434 

prognosis, 435 

symptoms, 434 

treatment, 435 
chronic, 437 

etiology, 437 

pathology, 437 

symptoms, 437 

treatment, 437 
fibrinous, 433 
forms of, 433 
plastic, 433 
with effusion, 435 

pathology, 436 

prognosis, 436 

symptoms, 435 

treatment, 436 
Perinephritis, 482 

definition, 482 

diagnosis, 483 

etiology, 482 

pathology, 482 

symptoms, 483 

treatment, 483 
Peritonitis, tubercular, 336 



Peritonitis, tubercular — contd. 

pathology, 336 

symptoms, 336 

treatment, 336 
Peritonsillar abscess, 164 

etiology, 164 

prognosis, 164 • 

symptoms, 164 

treatment, 164 
Perleche, 233 

etiology, 233 

symptoms, 233 

treatment, 233 
Pertussis, 399 

complications, 400 

diagnosis, 400 

etiology, 399 

Kilmer's belt in, 404 

pathology,400 

prognosis, 403 

quarantine in, 403, 428 

symptoms, 400 

treatment, 403 
Peters, 353 
Peterson, 569 
Pfeiffer, 95 
Pfeiff'er, bacillus, 407 
Pharyngitis, in measles, 365 
Phenolphthalein, 281 

and breast milk, 90, 108 
Phimosis, 492 

symptoms, 493 

treatment, 493 
Phlyctenular keratitis, 198 

etiology, 198 

symptoms, 198 

treatment, 198 
Pills, 74 
Pin worm, 287 
Pioscope, 94 
Plasmodium malarise, 347 

vivax, 350 
Pleurisy, 224 
diagnosis, 226 

from appendicitis, 300 

from pneumonia, 222 
etiology, 224 
pathology, 225 
physical signs, 213 
prognosis, 227 
symptoms, 225 
treatment, 227 
Pneumococcus, in tonsillitis, 159 
Pneumohydrothorax, 73 
Pneumonia, broncho-, 212 

diagnosis, 215 

etiology, 212 



INDEX. 



677 



Pneumonia, bronclio — contd. 

pathology, 212 

physical signs, 213 

prognosis, 216 

symptoms, 213 • 

treatment, 216 
croupous, 218" 
differential diagnosis, from ap 

pendicitis, 300 
fibrinous, 218 
lobar, 218 

diagnosis, 222 

etiology, 218 

pathology, 218 

physical signs, 220 

prognosis, 222 

symptoms, 218 

termination, 220 

treatment, 222 
and measles, 372 
pleuro-, 221 
Poikilocytes, 453 
Poikilycytosis, 455 
Poliomyelitis anterior acuta, 536 

diagnosis, 541 

epidemiology, 537 

etiology, 537 

history, 536 

paralysis, 540 

pathology, 538 

prognosis, 541 

symptoms, 538 

treatment, 542 
Politzer bag, 176 
Politzeration, 176 

Polymorphonuclear neutrophilic leu- 
cocytes, 453 
Polypi, nasal, 156 

symptoms, 156 

treatment, 156 
and chronic rhinitis, 156 
Pott's disease, 70. 545 

diagnosis, 546 

prognosis, 546 

symptoms, 546 

treatment, 546 

X-ray of, 546 
Powders, 74 
Poynton, 145, 437, 439 
Prepuce at birth, 23 
Prescription blank for modified milk, 

125, 126 
Presystolic thrill, 443 
Progress report, 56 
Proprietary foods, 148 
Proteid disagreement in breast milk, 
79 



Proteid — contd. 

increase of, in breast feeding, 98 
of milk, chemistry of, 119 
quotient, 119 

too much, in milk feeding, 144 
Pruritus, 595 

treatment, 595 
ani, 595 

in diabetes mellitus, 327 
Pseudohypertrophy of muscles, 552 
Pseudoleukemia, 464 
definition, 464 
diagnosis, 464 
patiiology, 464 
IJrognosis, 464 
symptoms, 464 
treatment, 464 
infantum, 464 
definition, 465 
etiology, 465 
pathology, 465 
symptoms, 465 
treatment, 465 
Pseudopernicious anemia, 464 
Psoriasis, 597 
Pterygium, 197 
etiology, 198 
symptoms, 198 
treatment, 199 
Pulmonary collapse, 203 

lesions, in rheumatism, 324 
Pulmotor in asphyxia of new-born, 

28 
Pulse, Corrigan's 444 
water hammer, 444 
Purpura, 465 

etiology, 465 
pathology, 466 
symptoms, 466 
treatment, 467 
fulminans, 466 
hemorrhagica, 466 

in rheumatism, 324 
Henoch's, 466 
rheumatica, 467 
simplex, 466 
symptoms, 466 
Pyelitis, 479 

definition, 479 

diagnosis, 480 

etiology, 479 

prognosis, 481 

symptoms, 480 

treatment, 481 

in typhoid fever, 311 

Pyelonephritis, 479 

Pyer's patches, 308 



678 



INDEX. 



Pylorus, stenosis of 243 

diagnosis, 244 

pathology, 243 

symptoms, 243 

treatment, 244 
Pyonephrosis, 479 
Pyopericardium, 437 

etiology, 437 

pathology, 437 

prognosis, 438 

symptoms, 438 

treatmeni, 438 

Q 

Quarantine in contagious diseases, 

426 
Quartan parasite, malaria, 353 
Quassia in treatment of thread 

worms, 287 
Quinsy, 164, 418 

E 

Rachitis, 507 

diagnosis, 511 

from chronic hydrocephalus, 

567 
from rheumatism, 324 
from syphilis, 365 
etiology, 507 
pathology, 508 
prognosis, olO 
symptoms, 509 
focal, 50y 
systemic, 510 
treatment, 511 
medicinal, 511 
and adenoids, 165 
and chronic rhinitis, 153 
Ralfe, 257 
Ramogen, 135, 149 

analysis of, 136 
Ranula, 240 

symptoms, 240 
treatment, 240 
Rectal feeding, 150 
Regions of chest, 62, 63 
Renal calculus, 481 
etiology, 481 
symptoms, 481 
treatment, 482 
colic in calculus, 482 
decapsulation, 487 
Refrigerator, Hess, 631 
Regurgitation, 442 
aortic, 444 
mitral, 442 
tricuspid, 446 



Rennet, liquid, 134 
Report of infants' progress, 56 
Respirations in new-born, 25 
Respiratory organs, disorders of, 200 
foreign bodies in, 200 

diagnosis, 200 

symptoms, 200 

treatment, 201 
Retropharyngeal abscess, 164 
Reynolds' test for acetone, 258 
Rhagades, 364 
Rheumatism, 322 

complications, 323 

diagnosis, 324 

from scorbutus, 324 

duration, 323 

etiology, 322 

pathology, 322 

prognosis, 325 

quarantine, 427 

symptoms, 322 

treatment, 325 
chorea in, 323 

as cause of heart disease, 431 
skin lesions in, 324 
subcutaneous nodules in, 323 
tonsillitis in, 323 
Rhinitis, acute, 152 

diagnosis, 152 

etiology, 152 

pathology, 152 

symptoms, 152 

treatment, 163 
atropic, 154 

etiology, 154 

prognosis, 154 

symptoms, 154 

treatment, 154 
chronic, 153 
Rib resection in empyema, 230 
Richardson, 301 
Rickets, 507 
Riga's disease, 240 

symptoms, 241 
Ringworm, 580 
Ritter, 40 
Rivinian gland, 240 
Roberts, 344 

Romanowsky's stain, 351 
Ross, 347 
Rotch, T. M., 39, 126, 128, 145, 367, 

436, 557 
Rotheln 376 

Royer, B. Franklin, 24, 560 
Rubber, bath tub, 78 

syringe, 75 
Rubella, 376 



INDEX. 



679 



Rubella — confd. 

complications, 378 
diagnosis, 378 

from measles, 373 
etiology, 376 
prognosis, 378 
quarantine, 4:'^6 
symptoms, 376 
treatment, 378 

Rubeola, 368 



Saccharomyces albicans, 238 
Sachs, 552' 

sign of chorea, 65 
St. Vitus' dance, 520 
Salmon, 112 

Salts, inorganic, in milk, 122 
Salvarsan, 367 
Sarcini ventriculi, 246 
Sarcoma of kidney, 488 
Sarcoptes scabies, 578 
Sattler's double coccus, 190 
Scabies, 578 

diagnosis, 579 

symptoms, 579 

treatment, 579 
Scales, nursery, 54 
Scalp, ringworm of, 580 
Scarlatina, 378 

complications. 382 

diagnosis, 384 

etiology, 378 

prognosis, 384 

quarantine, 427 

symptoms, 379 

treatment, 384 
prophylactic, 384 
symptomatic, 386 
Scarlet fever epidemics and milk. 

113 
Schamberg, 597 
Schaudinn. 354 
Schonlein's disease, 324, 467 
Schott, Xauheim baths, 80 
Schultz treatment of asphyxia, 28 
Schwartz, table of weighis, 57 
Schwer. 330 
Scleredema, 51 

etiology, 51 

pathology, 51 

symptoms, 52 

treatment, 52 
Sclerema, 51 
Sclerosis of spinal cord, 549 

diagnosis, 549 



Sclerosis of spinal cord — contd. 

etiology, 549 

pathology, 549 

prognosis, 549 

symptoms, 549 

treatment, 549 
Scorbutus, 504 

diagnosis from rheumatism, 324 
Score cards for dairies, 122 
Scraped beef, 143 
Scrofulous conjunctivitis, 193 
Scurvy, 324, 504 

diagnosis, 506 

etiology, 504 

pathology, 505 

prognosis, 506 

symptoms, 505 

treatment, o06 
Scutulum in favus, 580 
Searcv, 343 
Seat worm. 287 
Seibert, A., 82 

Seller's solution, 153, 154, 161, 176 
Sepsis of new-born, 45 

etiology, 45 

symptoms, 46 

treatment, 46 
Sera, animal, in hemorrhages. 41. 

468 ' 
Serum albumin, 477 
Shield, nipple. 87 
Sbiga bacillus. 246 
Shingles, 594 

Sigmoid flexure at birth. 20 
Silver solution in ophthalmia, ne-. 

onatorum. 195 
Sinapism, mustard, 77, 81 

turpentine, 77 
Skin, diseases of. 575 
examination, b9 
lesions in rheumatism. 322 
of new-born. 30, 35 
Sleep, disorders of. 531 
Sloane milk modifier. 606 
Smallpox. 394 
Smith, J. Lewis, 556 
Smith, Letchworth, 619 
Smithbank, 112 
Snow, 304 
Snuffles, 152 
Snvder, 292 
Soda bath, 79 
Soor, 238 
South worth, 134 
Spastic paralysis, hereditary, 551 

paraplegia. 567 
Sphenoid bone at birth, 18 



680 



INDEX. 



Sphincter ani, dilatation of, in as- 
phyxia, 28 
Specula, ear, 68 
Spina bifida, 18 
Spinal cord, diseases of, 536 
sclerosis of, 549 

diagnosis, 550 

etiology, 549 

pathology, 549 

symptoms, 549 

treatment, 550 
syphilis of, 548 

diagnosis, 548 

pathology, 548 

spastic paraplegia in, 548 

symptoms, 548 

treatment, 548 
tumors of, 547 

diagnosis, 547 

prognosis, 548 

symptoms, 547 

treatment, 548 
Spirocheta, 363 
Spleen, at birth, 20 
Spotted fever, 556 
Sprue, 31, 238 
Squires' sign, 51o 
Staining malaria parasite, 351 
Stanton's percussion hammer, 73 
Staphylococcus in tonsillitis, 160 
Staphyloma, anterior, 195 
Starch, digestion, as shown by stools, 

138 
Starr, 537 

Starvation temperature, 49 
Statistics, mortality and morbidity 

influenced by milk, 115 
Status lymphaticus, 469 
Stearin 'in milk, 120 
Steelyards for weighing, 41 
Stenosis of pylorus, 243 
Stephens, 349 
Sterilization of milk, 116 
Sternum at birth, 18 
Stethoscope, 70 
Still born, 25 
Stimulants, 76 
Stoelker, 433 
Stomach, at birth, 20 
bacteria in, 237 
diseases of, 245 
washing, 82 

apparatus for, 83 
Stomatitis, 234 
catarrhal, 234 

symptoms, 234 

treatment, 235 



Stomatitis — contd. 
gangrenous, 236 

etiology, 236 

pathology, 236 

prognosis, 237 

symptoms, 236 

treatment, 237 
herpetic, 234, 235 

etiology^ 235 

pathology, 235 

symptoms, 235 

treatment, 235 
parasitic, 238 
syphilitic, 239 
ulcerative, 234 

etiology, 235 

pathology, 235 

symptoms, 235 

treatment, 235 
Stone in kidney, 481 
Stools, curds in 144 

number in 24 hours, 246 
Strawberry tongue, 68, 380 
Streptococcus, in tonsillitis, 160 
Stridor, congenital laryngeal, 170 
Stye, 188 

Stibcutaneous nodules in rheuma- 
tism, 322 
Sudamina, 324, 576 

treatment, 576 
Sugar, content in milk, 131 

too much in milk feeding, 144 

of milk solution at birth, 88 

solution, 131 
Summer diarrhea, 263 
Suppositories, 75 
Suprarenal glands at birth, 21 
Surgery of intestines, 296 
Sutures at birth, 17 
Sydenham, 347 

chorea, 520 
Sylvester treatment of asphyxia, 27 
Symblepharon, 191 
Synechia, anterior, 195 
Synovitis, in syphilis, 364 
Syphilis, congenital, 365 

diagnosis, 365 

etiology, 361 

hereditaria tarda, 365 

mode of transmission, 362 

pathology, 363 

prognosis, 365 

symptoms, 364 

treatment, 366 

of special symptoms, 367 
and anemia, 447 
of mouth, 239 



INDEX. 



681 



Syphilis — contd. 

of spinal cord, 548 
Syringe for enemata, 75 
'glass, 82 

T 
Tabes and Freidreich's disease. 550 
Taclie cerebrale in tubercular men- 
ingitis, 334 
Tachycardia, 440 
symptoms, 449 
treatment, 449 
Talbot. 144 

Tallquist hemoglobin scale, 452 
Tampon, in otitis. 178 
Tape for mensuration, 73 
Tapeworm, 293 
Teeth, temporary and permanent, 58 

Hutchinson, 60, 365 
Temperature, QQ 

chart in otitis media, 180 
method of taking, 66 
of new-born, 35 
starvation, of new-born, 49 
Temporal bones at birth. 18 
Tenia. 293 

symptoms. 294 
treatment, 294 
medio^anellata. 294 
solium, 293. 294 
eggs of. 293 
head of. 293 
Testicles, at birth, 23 
operation for, 499, 492 
undescended, 499 
Tetanus. 49 

etiology, 49 
pathology, 50 
symptoms, 50 
treatment, 51 
Tliayer, 354 

Therapeutics of infancy and child- 
hood, 74 
Tliermos bottle as cause of illness 

from changes m milR. 114 
Thorax at birth, 18 
Threadworms. 287 
Thrill, presystolic, 443 
Throat diseases of. 152 

examination of, 66 
Thrush. 31. 238 
etiology, 238 
symptoms, 238 
treatment, 238 
Thymus gland, 469 
at birth, 19 
enlarged, 469 

symptoms of, 469 



Thyroid myxedema. 475 
Tinea circinata, 580 
pathology, 581 
symptoms, 580 
treatment. 581 
favosa, 583 
diagnosis, 584 
etiology, 583 
pathology, 584 
prognosis, 584 
symptoms, 584 
treatment, 584 
tonsurans, 582 
diagnosis, 582 
etiology, 581 
pathology, 581 
prognosis, 582 
symptoms, 582 
treatment, 582 
Tongue, depressor, 68 
diseases of, 233 
epithelial desquamation, 233 
examination of, 68 
geographical, 233 
of scarlet fever, 380 
strawberry, 68, 380 
tie. 240 

treatment, 240 
Top milk, method of modification, 

130 
Tonsillitis, acute catarrhal, 159 
etiology, 157 
prognosis, 158 
symptoms, 157 
treatment, 158 
follicular, 159, 418 
complications, 160 
diagnosis, 160 
etiology, 159 
treatment, 160 
in rheumatism. 323 
Tonsillectomy, 162 
Tonsillotome^ 162 
Tonsillotomy, 162 
Tonsils, chronically enlarged. 161 
symptoms of. 161 
diseases of, 156 
Torti. 347 

Tothe's diagnostic measures. 516 
'Townsend. 39. 41 
Trachea, at birth, 18 
Trachoma.- 190 
etiology, 190 
pathology, 191 
prognosis, 191 
sequelae, 191 
symptoms, 191 



682 



INDEX. 



Trachoma — contd. 
treatment, 192 
roller forceps for, 191 
Transfusion of blood in pernicious 

anemia, 458 
Tricuspid regurgitation, 446 
pathology, 446 
physical signs, 446 
prognosis, 446 
symptoms, 446 
stenosis, 446 
etiology, 447 
pathology, 447 
physical signs, 447 
symptoms, 447 
Trismus nascentium, 49 
Tubercle bacillus, bovine and human 

type, 116 
Tuberculin, 339 

test for cattle, 111 
Tuberculosis, 329 
chart of, 333 

British Royal Commission on, 109 
diagnosis, 338 

calmette method, 339 
cutaneous method, 340 
from bronchopneumonia, 215 
from i>seudoleukemia, 464 
Moro method, 341 
etiology, 329 
frequency of, 330 
ophthalmic test of, 339 
pathology, 329 
percentage of, in cows. 111 
port of entry, 330 
symptoms, 333 
and cows, 110 
and measles, 365 
and milk, 109 
in typhoid fever, 315 
of adrenal glands, 472 
glands, 329 
intestines, 329 
kidney, 330 
lungs, 330 
meninges, 330 
prevention, 342 ' 
transmission of, through milk, 

cases, 109 
treatment, 342 
varieties, 331 
Tubes, intubation, 423 
Tubotympanic, catarrh, 175 

differential diagnosis of, 175 
etiology, 175 
pathology, 175 
prognosis, 176 



Tubotympanic — contd. 

symptoms, 175 

treatment, 176 * 

Turbinates, hypertrophied, 69 

hypertrophy of, in rhinitis, 152 
Typhoid fever, 307 

age, 307 

bacteriology, 308 

chart of, 310 

complications, 312 

definitions, 307 

diagnosis, 314 

duration, 303 

etiology, 307 

incubation, 308 

pathology, 308 

prognosis, 316 

symptoms, 308 

treatment, 316 
diet, 318 

management, 317 
prophylactic, 316 
stimulation, 319 
aphasia in, 313 
appendicitis, 316 
bowels in, 320 
chorea in, 313 
convalescence, 321 

diet in, 321 
Ehrlich's reaction, 311, 314 
epidemics and milk, 113 
eruption in, 311 
fever, 319 

periods of, 309 
furunculosis in, 314 
hemorrhage in, 312, 321 
malaria in, 316 
melancholia in, 313 
otitis media in, 313 
perforation in, 312 
pneumonia in, 313 
pyelitis in, 316 
tuberculosis, 315 
tvmpanites, 320 
Widal test, 311, 314 



U 



Ulcerations at angle of mouth, 233 
etiology, 233 
symptoms, 233 
treatment, 233 
Ulcerative stomatitis, 235 
Umbilical cord, dressing of, 29 
ligature of, 28 
hemorrhage, 37 
hernia, 20, 42 



INDEX. 



683 



Umbilicus, granulating, 37 

treatment, 37 
Uncinaria duodenalis, 291 
Urethra, male, at birth, 21 
Urethritis, 495 
gonorrheal, 495 
diagnosis, 496 
symptoms, 496 
treatment, 496 
simple, 495 

treatment, 495 
Uric acid, 476 
infarcts, 21 
Urinal, Chapin, 476 
Urine, the, 476 

collection for examination, 85, 476 
incontinence, 491 

in pertussis, 399 
in infants and children, 476 
in pyelitis, 479 
of new-born, 35 
Urticaria, 596 
etiology, 596 
pathology, 596 
prognosis, 596 
symptoms, 596 
treatment, 596 
factitata, 590 
in rheumatism, 324 
in vaccination, 394 
Uterus at birth, 24 
Uvulitis, 163 

symptoms, 163 
treatment, 163 



Vaccination, complications, 393 

history, 391 

normal course, 393 

symptoms, 393 

technic of, 391 

virus, selection of, 392 
Vaccinia, 393 

complications, 393 

course, 394 

history, 391 

symptoms, 393 
Vail's method of everting the lids^ 

197 
Valvular lesions, combined, 447 

prognosis, 447 

treatment, 447 
of heart, congenital. 431, 432 
Van Slyke, 119, 120, 133 
Vapor, calomel, inhalations, 76 
Vaporizer, 207 



Varcella, 389 

complications, 390 

diagnosis, 390 

etiolog^^, 389 

gangrenosa, 390 

prognosis, 391 

quarantine, 428 

symptoms, 389 
systemic, 390 

treatment, 391 
Variola, 394 

complications, 397 

confluent, 396 

definition, 394 

diagnosis, 397 

eruption, 395 

etiology, 395 

hemorrhagic, 396 

prognosis, 397 

quarantine, 427 

symptoms, 395 

treatment, 397 
prophylactic, 397 
Vernal catarrh of conjunctiva, 192 
Vernix caseosa, 30 
Version, 47 

Vertebral caries and retropharyn- 
geal abscess, 164 
Viscera malposition of, 24 
Vision in nervous diseases, 515 
Vissman, Dr. Louis, 112 
Vomiting, cyclic, 256 
Von Jaksch, 464 
Von Noorden, 461 
Von Pirquet, 339, 340, 421 
Vulvovaginitis, 496 

complications, 497 

etiology, 496 

prognosis, 497 

symptoms, 497 

treatment, 497 

W 

Walker-Gordon Laboratorv, 125, 128 
Wallace, 303 
Wangenbrand, 236 
Washing, stomach, 82 
Wassermann reaction, 362 
Water, albumin, 141 

to nursing baby, 87 
Wasting disease, 501 
Wax, impacted, in auditorv canal, 
174 
treatment, 174 
Weaning, 99 
Week's bacillus, 189 



684 



INDEX. 



Weicliselbaum, 556 

Weight, tables for calculation, 55 

at birth, 53 
Weil, Emile, 42 
Werlhoff's disease, 466 
Werner, F. W., 318 
Westcott's cha.rt for milk modifica- 
tions, 599 
formulae for milk modifications, 
598 
Wharton's jelly, 28, 37 
Whey, 133 

cream mixtures, 134, 609 

analysis of, 134 
feeding, 133 
Whitehall-Tatum bottle, 124 
Whooping-cough, 399 
etiology, 399 
quarantine, 403, 428 
Wickman, 537 



Widal reaction, 311, 314 
Wilcox, 327 
Williams, 41 
Wilson, 24 

Wlnckel's disease, 39 
Winslow, 95 
Wolfr-Eisner, 340, 341 
Wine whey, 133 
Worm, hook, 286 

pin, 287 

round, 289 

seat, 287 

tape, 293 

thread, 287 
Wright's method of inoculation in 
vulvovaginitis, 497 



Young's rule for dosage, 74 



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